Appeals Coordinator

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🕒 Junho 17

🔔 Pennsylvania – Remoto

🔔 Pennsylvania – Remote

⏰ Tempo Integral

🟡 Pleno

🟠 Sênior

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Geisinger

SiteLinkedInTodas as Vagas

10.000+ funcionários

Fundada em 1915

🏥 Saúde

💊 Farmacêutico

🧘 Bem-estar

Healthcare • Pharmaceuticals • Wellness

Geisinger é uma organização de saúde que atende comunidades na Pensilvânia há mais de um século, oferecendo serviços médicos essenciais e soluções inovadoras em saúde. A organização enfatiza a diversidade, o desenvolvimento de carreira e a criação de um ambiente de apoio para seus funcionários, enquanto se esforça para melhorar a saúde e o bem-estar de seus pacientes por meio de diversos programas e iniciativas comunitárias. Geisinger é reconhecida como um dos sistemas de saúde mais inovadores e está comprometida em moldar o futuro da saúde com foco no cuidado ao paciente e na inclusividade.

Descrição

• Provides support in administration of the Appeals and Grievance process. • Serves as a liaison between Members and the Plan with appeals regarding denied claims/services, referrals, membership and benefit issues and concerns regarding quality of care or service. • Presents Member appeals to the Plan Medical Staff and Center for Medicare/Medicaid Services contracted reviewer. • Prepares and facilitates Member appeals, complaints and grievances by communicating directly with Members, their Representatives, Vendors and Medical Providers and their Representatives to obtain the necessary information to complete the appeal process successfully within the time period allowed by regulation. • Investigates the full details of the appeal and complaints and grievances by consulting with, but not limited to, health care providers, legal services, internal medical staff and administration. • Provides timely and accurate documentation of all communications with involved parties within both the individual case file and departmental tracking database. • Ensures that all complaint, appeal and grievance time frames are met as dictated by guidelines set forth by the Department of Labor (DOL), the Department of Health (DOH), the Department of Insurance (DOI), the National Committee for Quality Insurance (NCQA), and the Centers for Medicare and Medicaid Services (CMS). • Implements regulatory changes to current practices, policies and procedures within the Department. • Maintains a complete and accurate database via departmental software for reporting and tracking and trending purposes. • Conducts regular audits of own files and data entry to ensure timely, accurate and appropriate documentation. • Coordinates activities for review committees and educational sessions with other Health Plan departments to ensure overall compliance is maintained. • Acts as the primary resource regarding the complaint, appeal and grievance processes to all other Health Plan and external entities, communicating with all entities involved throughout the appeals and grievance process. • Maintains strict compliance with all applicable laws and regulations set forth by the Federal and State regulatory bodies, continually reviewing updates as pertains to regulatory changes and implement those changes within current departmental practices, policies and procedures.

🎯 Requisitos

• High School Diploma or Equivalent (GED)- (Required) • Minimum of 5 years-Relevant experience* (Required) • Skills: Communication, Multitasking, Working Independently

🏖️ Benefícios

• We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners. • Encourages an atmosphere of collaboration, cooperation and collegiality.