American Health Plans, a division of Franklin, Tennessee-based American Health Partners Inc., owns and operates Institutional Special Needs Plans (I-SNPs) for seniors who reside in long-term care facilities. In partnership with nursing home operators, these Medicare Advantage plans manage medical risk by improving patient care to reduce emergency room visits and avoidable hospitalizations.
Appeals and Grievances Team Leader
Location
United States
Posted
35 days ago
Salary
0
Seniority
Mid Level
No structured requirement data.
Job Description
Appeals and Grievances Team Leader
TruHealth
Role Description The purpose of this position is to provide lead level support to the Appeals and Grievances team with the direct assistance of the Director of Claims Operations. This includes overseeing the processing, tracking, and following up on all medical necessity and administrative denials, appeals, grievances, and disputes for Medicare Advantage members in accordance with Medicare guidelines and regulations. The Appeals and Grievances Team Leader is a critical team player who works in a fast-paced, ever-changing environment with a passionate team and must deliver daily. Essential Functions - Capture, investigate and respond to all complaints regarding customer grievances and appeals. - Oversee claim payment disputes provision of service and benefit coverage issues. - Conduct pertinent research to evaluate, answer, and close appeals. - Ensure appropriate resolution to inquiries, grievances and appeals within specified timeframes established by regulatory/accreditation agencies or customer needs. - Assist members when filing appeals; educate members, document and route the information appropriately. - Prepare response letters, notifications, and acknowledgements for members and provider complaints, grievances and appeals. - Maintain grievance information and supporting documentation in accordance with all state, federal, NCQA, URAC and other regulatory agency standards/regulations. - Escalate issues appropriately or work with other departments to resolve member issues. - Ensure all HIPAA and State requirements/regulations are always adhered to. - Identify issues and root causes of appeals and disputes for plan management and compliance. - Identify and report trends and/or areas of opportunities to supervisor. - Maintain and update appeal and grievance policies and procedures, member correspondence materials, and process manuals. - Perform internal audits of grievance and appeals process. - Maintain privacy and confidentiality of records, conditions, and other information relating to residents, employees and facility. - Encourage an atmosphere of optimism, warmth and interest in patients’ personal and health care needs. - Meet critical time frames on a frequent and regular basis. Qualifications - Excellent communication skills and active listening. - Positive, engaging customer service skills. - Ability to work cooperatively with internal departments and external stakeholders. - Ability to perform in potentially stressful situations, such as state, federal, NCQA, URAC or other regulatory/accrediting agency audits. Requirements - Minimum (3) three years’ health plan experience; insurance, compliance, managed care, or quality assurance preferred. - Minimum (3) years of Grievance and appeals experience preferred, specifically within a Medicare and/or Medicare Advantage context. - Minimum two years of demonstrated leadership skills in claims and/or appeals and grievances. - Proven track record for improving processes and problem-solving skills. - Ability to motivate team members while also possessing strong leadership skills. - Experience working with physicians and clinicians in the appeals and grievance space, preferred. - Knowledge and understanding of complaint and appeal procedures. - Knowledge of managed care, particularly utilization management processes. - Knowledge of NCQA, HEDIS or general accreditation requirements and guidelines for utilization management, denials and appeals. - Familiarity with Appeals processes and regulatory requirements related to customer service experience. - Proven ability to problem-solve and make solid and well-researched decisions. - Qualifying criminal background. Education Requirements - High school diploma required. - Associates degree preferred. - Successfully completed college courses in relevant fields to compensate for experience preferred. - Medicare experience preferred.
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