Summary:  

The Appeals and Grievances coordinator, Senior position, is focused on the processing of customer and provider Medicare and Commercial appeals and grievances.  This associate may screen incoming complaints, process medical necessity, utilization management and claims appeals, initiate Independent Review Organization external reviews as well as respond to CMS and department of insurance inquiries.  The position will promote quality patient care and customer service/satisfaction, while promoting safety, cost efficiency and a commitment to the Continuous Quality Improvement Process.

The Appeals & Grievance Coordinator, Senior, will interact on a daily basis with the Customer Service Department, Medical Management Department, Medical Directors, enrollees, providers and TPA Staff as may be necessary to effectively resolve appeals, complaints and quality of care or service issues. This role is also responsible for various quality assurance activities, including auditing and monitoring activities of the processed cases and correspondence and universe preparation.  

Essential Duties and Responsibilities:

• Interact with internal departments, such as Customer Service, Medical Management, medical directors, Claims and Provider Relations, as well as members, providers and other external entities to effectively process appeals and claims in a timely and appropriate manner
• Communicate decisions with appropriate, understandable correspondence
• Work directly with the Manager to meet the department's needs
• Serve as a preceptor and trainer to new and/or less experienced staff 
• Adverse Determination and Appeals Tracking 
• Coordination of Appeals, Adverse Determinations and Grievances 
• Corresponds with members, providers and regulators regarding decisions and actions 
• Engages in the process of coordinating independent reviews 
• Revises and amend policies and procedures based on changes in TDI or other regulatory statutes.
• Works collaboratively with the Claims, Customer Service and Medical Management Departments
• Communicate, collaborate and cooperate with internal and external stakeholders.
• Adheres to all Compliance/Program Integrity requirements.
• Complies with HIPAA Regulations Ensures safe care for patients, staff and visitors; 
• Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency
• Supports department-based goals which contribute to the success of the organization
• Communicates issues and trends to the unit’s manager
• Serves as a preceptor, mentor and resource to less experienced staff
• Assists with internal monitoring audits
• Assists with CMS audits 
• Assists with additional training and remediating for department CAPs
• Other duties as assigned. 

Education/ Experience:

• A Bachelor’s or associates degree in a related field, in lieu of a degree, a high school diploma and five years in a managed care environment performing in appeals review/investigation function will be considered.
• Five years of health insurance/managed care experience performing Appeals and Grievances functions.
• Knowledge of healthcare terminology preferable
• Strong written and verbal communication skills
• PC proficiency to include Microsoft Office products
• Some travel in the Houston metro area may be required. 

Skills:

• Knowledge of healthcare delivery
• Ability to work in a fast-paced environment with changing priorities
• Ability to work with others in a matrixed environment
• Demonstrated written communication skills 
• Demonstrated time management and priority-setting skills
• Demonstrated problem-solving skills and organizational skills 
• Demonstrated ability to converse with and collaborate with physicians and physician personnel
• Reasoning ability to identify and define problems, collect data/information, establish facts, and draw valid conclusions, make decisions and implement changes related to TDI and Federal regulations 

About Apex Health Solutions

Apex Health Solutions powers payers and providers choosing to engage in value-based risk contracting. Apex’s unique solutions create alignment between payers and providers, generating unparalleled value. Combined with Apex’s experienced and successful industry leadership, our focal point remains on improvement in patient quality, satisfaction and overall cost of care.