Job Description

Summary Description:

The Appeals & Grievances Specialist I is responsible for knowledge of WHA’s practices, processes, policies and procedures, benefit guidelines, and contractual agreements. This position is also responsible for meeting all regulatory guidelines and timeframes with regards to appeal and grievance (complaint) case processing for Western Health Advantage (WHA). This includes, but is not limited to, maintaining knowledge of the CA Department of Managed Healthcare (DMHC) regulations and the National Committee for Quality Assurance (NCQA) credential standards for accreditation pertaining to appeals and grievances, as well as Privacy Practices for the Use and Disclosure of Protected Health Information (PHI) regulations, with regards to member information and medical records. This is a fast-paced position that involves extensive interaction with internal departments, external entities, to include medical groups, providers, an authorized representative, or broker.

Representative Duties:

• Serve as the assigned specialist to perform intake, research and investigation of member issues that are related to appeals and/or grievances, while effectively representing the member’s interest from initial triage.

• Quickly learn and retain appeals and grievances classifications, which include, but are not limited to, a request to change an initial decision or modification, or to grieve, with regard to enrollment/disenrollment, premium billing, access and care coordination, service, medical and prescription benefits and prior authorizations, claims processing, medical and prescription reimbursement requests, deductibles and out-of-pocket maximums, utilization management, quality of care, legal/compliance matters, or any aspect related to their health plan or its delegated entities.

• Identify urgency of a case, screening of an expedited request, recognition of a potential quality issue, violation of PHI/HIPAA, medical fraud, breach of contract or when a request exceeds the statutes of limitations.

• Perform outreach to members or authorized representative(s), when necessary, to obtain additional information and clarification in relation to the grievance/appeal.

• Promptly perform intake utilizing multiple systems for initial intake and research.

• Triage and task to next level of support or to the appropriate clinical staff for further review.

• Perform outreach and provide notification to members regarding expedited requests and whether or not it met criteria, followed by their rights to contact the DMHC.

• Work with WHA’s internal departments, contracted medical groups, and hospital systems to request all pertinent information relevant to the member’s appeal/grievance.

• Evaluate information received from appropriate departments or entities to ensure that the information provided is sufficient for a Plan determination.

• Perform follow-up on appeals and/or grievances, as assigned, and contact the appropriate departments or entities (internal or external) for a thorough response.

• Maintain accurate and thorough documentation of outreach, communications, medical records and chart notes, decisions, and appeal review committee actions.

• Customize all written acknowledgement letters to summarize the member’s request.

• Assist with resolution letters to include case specifics which are established and based on a determination of benefit guidelines and/or medical necessity, to include education to members.

• Report possible trends or increased issues when identified during intake.

• Participate and engage in process improvement plans, to include training improvement opportunities.

• Effectively communicate with team members and provide support to A&G staff that have increased responsibilities.

• Provide support to the A&G Coordinator, to include backup with monitoring and handling of incoming/outgoing email, mail, and faxes.

• Perform other duties and special projects as assigned

Qualifications:

• High School Diploma.

• 2 years’ experience in a similar role (appeals and grievances) in the healthcare industry; preferably HMO, with increased responsibilities.

• Experience with HMO claims adjudication, as well as referrals and authorizations (utilization management), are preferred.

• Intermediate computer skills, including electronic mail, routine database activity, word processing, spreadsheet, graphics, etc. Specifically, Microsoft Word and Excel.

• Must be able to speak, read, write (intermediate writing skills), and understand the primary language(s) used in the workplace.

Salary:

$22.00- $25.00 Hourly

Western Health Advantage is committed to providing equal employment opportunities to employees and applicants for employment on the basis of merit and without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, physical or mental disability, medical condition, genetic information, marital status, ancestry, military or veteran status, or any other basis made unlawful by federal or state law. (EOE)

Western Health Advantage values and supports the unique talents and strengths that each employee brings to our organization. Collaborating with the best and the brightest means a dynamic, fulfilling work experience for you — and excellent customer service for our members.

*WARNING: Please beware of phishing scams that solicit interviews or promote work-at-home opportunities, some of which may pose as legitimate companies. Please be advised that Western Health Advantage will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the to the Federal Trade Commission by selecting the ‘Rip-offs and Imposter Scams’ option.’

Job Tags

Hourly pay, Full time, Contract work, Work experience placement,

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