This position requires the ability to work independently researching and reviewing inquiries from members and providers. Also requires knowledge of benefit interpretation, claims reviews, CPT and ICD coding. Responsible for analyzing, researching, and managing appeal/grievance inventories from members and providers. Respond to inquiries using verbal and written forms of communication.
MAJOR JOB RESPONSIBILITIES
* Research and provide resolution to issues such as claim denials, member and provider complaints, and reconsideration and redetermination requests. * Review and respond to complaints, grievances and appeals within the stated time frame for each request. * Ensure 95% compliance with the Center for Medicare and Medicaid Services (CMS) guidelines is met by * adhering to all state and federal regulations. * Analyze and resolve customer inquiries by adhering to CMS guidelines and CHRISTUS Health Plan * internal policies and procedures. * Actively communicate with other associates to guarantee accurate and timely responses to inquiries * involving internal/external customer needs. * Be proactive in educating members, providers and others about CHRISTUS Health plans appeal/grievance process, plan terminations, contract terminations and benefit summary. * Certify that providers and members are reimbursed accordingly using Medicare or other applicable plan reimbursement policies and procedures. * Maintain accurate and timely responses to inquiries and generate appropriate letters to members and * providers informing them of appeals/grievance decisions. * Provide recommendations and direction to both servicing providers and members in attempt to eliminate repeated disputes between providers and CHRISTUS Health Plan. * Follow the CHRISTUS Health guidelines related to Health Insurance Portability and Accountability Act * (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI). * Attend weekly and monthly team and department meetings as appropriate. * Ability to sit for long periods of time. * Ability to organize and prioritize work to meet deadlines. * Ability to work occasional long or irregular hours. * Ability to work flexible work schedule including evenings and weekends. * Good writing skills.
* Associate Degree Preferred. * Previous Appeals and Grievance experience with Managed Care Plans. * Good typing and letter writing skills. * Excellent written and oral communication skills. * Excellent research and analytical skills. * Basic computer knowledge. * Excellent customer service skills. * Ability to work well with diverse groups of individuals. * Utilizes effective communication and conflict management skills. * Minimum of one year customer service experience. * Minimum of one year experience with Managed Care Plans.