Appeals and Grievances Specialist

🕒 Julho 21

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Curana Health

SiteLinkedInTodas as Vagas

1001 - 5000 funcionários

🏥 Saúde

🤝 B2B

⚕️ Seguro de Saúde

Healthcare • B2B • Healthcare Insurance

A Curana Health é uma provedora de serviços de saúde focada em cuidados primários para idosos e serviços clínicos no local em comunidades de enfermagem especializada e moradias para idosos. A empresa faz parcerias com operadores, pagadores e planos Medicare Advantage para implementar modelos de cuidado baseado em valor, oferecendo equipes de cuidados lideradas por médicos, serviços de diretores médicos, coordenação de cuidados (incluindo RPM e APCM), saúde comportamental e cuidados paliativos. A Curana enfatiza a redução de readmissões hospitalares, quedas e polifarmácia, ao mesmo tempo em que melhora a satisfação dos residentes por meio de um cuidado integrado, baseado na comunidade, apoiado por tecnologia e parcerias com pagadores.

Descrição

• Investigate and resolve member and provider appeals and grievances in a professional, accurate, and timely manner while meeting all contractual and regulatory timeframes. • Maintain a clear understanding of the differences between medical necessity appeals and claim appeals and apply appropriate processes accordingly. • Manage appeals and grievance cases from intake through final resolution, including receiving, logging, tracking, monitoring, documenting, requesting supporting documentation, investigating, auditing, resolving, and reporting on cases. • Respond to member and provider appeals and grievances independently and with minimal supervision. • Interface with members and providers regarding the status, process, and outcomes of complaints, appeals, and grievances. • Prepare all appeal and grievance-related correspondence, including acknowledgment letters, determination letters, outcome notifications, and correspondence for escalated levels of review. • Prepare, attend, and present appeals and grievances documentation for plan hearings, regulatory reviews, audits, and other compliance-related activities as needed. • Accurately document all appeal and grievance activities, follow-up actions, and final outcomes in designated systems while maintaining comprehensive and secure case files. • Generate reports, identify trends, and provide recommendations for quality improvement initiatives and operational enhancements. • Communicate detailed risk management concerns and compliance-related issues to leadership within established timeframes. • Review appeal and grievance correspondence and proactively obtain additional information from appellants, providers, or other stakeholders as necessary. • Partner closely with member advocates and internal stakeholders to facilitate effective grievance resolution and an exceptional member experience. • Assist in coordinating peer review activities involving internal Physician Advisors and external review vendors. • Collaborate with Utilization Management, Claims, Provider Network, Legal, Compliance, and other business partners to ensure appeal and grievance decisions align with all regulatory, contractual, and organizational requirements. • Work with leadership and external vendors to resolve complex, high-profile, and escalated appeals and grievance cases.

🎯 Requisitos

• High school diploma or GED required. • Minimum of three (3) years of experience managing Medicare Advantage appeals and grievances. • Experience working for a Medicare Advantage health plan. • Experience within Medicare Advantage health insurance, including appeals, grievances, customer service, and complaint resolution. • Working knowledge of Medicare Advantage regulations, appeals processes, grievance procedures, and complaint resolution requirements. • Experience investigating and resolving complex member and provider issues in a highly regulated healthcare environment. • Strong written and verbal communication skills, including the ability to prepare professional correspondence, determination letters, and case documentation. • Proficiency with Microsoft Office applications, including Word and Excel. • Strong analytical, organizational, problem-solving, and critical-thinking skills. • Ability to effectively manage multiple priorities, meet strict deadlines, and maintain a high degree of accuracy and attention to detail. • Ability to interpret, apply, and adhere to regulatory requirements, policies, and procedures.

🏖️ Benefícios

• Health insurance • Retirement plans • Paid time off • Professional development opportunities