Manages submission, intervention and resolution of appeals, grievances, and/or complaints from Client's members and related outside agencies as a part of the integrated Healthcare Services Team. Conducts pertinent research, evaluates, responds and completes appeals and other inquiries accurately, timely and in accordance with all established regulatory guidelines. Prepares appeal summaries and correspondence and documents information for tracking/trending data.
- Enters denials and requests for appeal into information system and prepares documentation for further review.
- Assure timeliness and appropriateness of all Provider appeals according to state and federal and Healthcare guidelines.
- Work with Customer Service to resolve balance bill issues and other member complaints regarding providers.
- Prepare responses to provider grievances / appeals.
- Elevates appeals to the appropriate committee and/or manager per protocol. Prepares and assists in the preparation of the narratives, graphs, flowcharts, etc. to be utilized for presentations and audits.
Required Education/ Required Experience:
- 6 months -2 years of handling claims/appeals experience.
- Familiarity with Medicaid and Medicare claims denials and appeals processing, and knowledge of NCQA guidelines for appeals and denials.
denials , appeal , grievances , Medicare claims, Post Service Appeal, Pre Service Appeal