Appeals and Grievance Specialist

Now hiring a Appeals and Grievance Specialist

Responsible for responding to verbal and written complaints, grievances, and requests for appeals that involve complex matters. Responsible for performing comprehensive research to clarify facts and circumstances. Able to identify the root cause for an issue. Assure that customers and health plan providers receive exceptional service when acknowledging, discussing, documenting or responding to their issue of dissatisfaction. Makes initial decision regarding resolution of complaints, grievances or appeals based on completed research. Responsible for making sure issues are categorized and can be reported to internal stakeholders, oversight committees and regulatory agencies. Able to act as a member advocate in each case, comparing the grievant/appellants issues with the organization s documented facts

How you belong matters here.

We value our employees' differences and find strength in the diversity of our team and community.

At Presbyterian, it's not just what we do that matters. It's how we do it - and it starts with our incredible team. From Information Technology to Food Services and beyond, our non-clinical employees make a meaningful impact on the healthcare provided to our patients and members.

Why Join Us

Full Time - Exempt: No
• Job is based Rev Hugh Cooper Admin Center
• Work hours: Days
• Benefits: We offer a wide range of benefits including medical, wellness program, vision, dental, paid time off, retirement and more for FT employees.

• High School education or G.E.D. equivalent required. Associates Degree preferred.
• Three years experience in a customer service setting required of which one year in a health care environment is preferred.
• Experience in managed care field such as Claims or Member Services strongly preferred.
• Experience with healthcare databases is preferred

• Perform research related to the facts and circumstances of a member and provider complaint, appeal, or grievance.
• Gathers necessary documents (from internal and external resources) related to an appeal, grievance or complaint to develop a complete file. Gathers information from clinical sources, medical records, chart reviews, admitting records, patient financial records, and from subject matter experts in order to research the facts of all complaints, grievances and appeals. Uses available documentation including DART, provider manuals, member contracts and online policies and procedures to support accurate and consistent decisions relating to claims payment, authorizations, contractual issues, servicing and care standards, and all other operational aspects of the organization.
• Required to document the substance of each complaint, grievance or appeal case according to legal requirements.
• Responsible for making direct verbal contact with members and providers who have filed a complaint, grievance or appeal during research process in order to fully document the issue. Required to communicate in writing with customers, members, providers or designated representative; using the regulatory compliant format on all issues both for acknowledgment and resolution. All written correspondence must be reviewed for regulatory statutes and requirements for all customer types. Must be able to professionally articulate orally and in writing an understanding of complex issues and detailed action plans.
• Responsible for reviewing research performed by other referral sources, department heads, other departments and conduct more detailed investigative research into the matter to resolve issues of complaint, grievance or appeal.
• Responsible for making decisions in cases of dispute that were not decided or resolved by other referral sources or departments. Such decisions will be made using policy and guidelines, detailed research and applying a standard of reasonableness, considering all actions previously taken by others.
• Responsible for application of contract language from member contracts, provider contracts and employer contracts in researching and deciding outcomes.
• Works closely with Legal/Risk Management, Medical Staff, Medical Directors, Department Directors, regulatory representatives, and outside professional consultants to achieve consistent outcomes in cases of complaints, grievances and appeals.
• Presents completed research file along with recommendation and decision for resolution to the appropriate Appeals and Grievance Coordinator within the time period necessary to remain in compliance with regulatory requirements for appeals, grievances or complaints.
• Responsible for file and documentation preparation of all cases that proceed to further internal or external review and for regulatory and oversight audit activities.
• Responsible for communicating complaint resolutions/decisions to grievant, legal representatives and providers both telephonically and in writing.
• Responsible to know regulatory requirements for member and provider complaint, grievance and appeals processing.
• Logs complaints, grievances, and appeals issues, and identifies trends. Must be proficient with database entry and categorization of issue type, receipt date, timeframe for acknowledgement and resolution processing.
• Required to document or phone log all issues processed and categorizes accordingly.
• Monitor effectiveness of resolutions/outcomes as a result of the complaint/grievance/appeal process.
• Assists in the development of process improvement functions that result from complaints, appeals and grievance processing.
• Identify errors and inconsistencies that require revisions to guidelines or system modifications, bringing errors to the attention of appropriate personnel in each affected department or quality committee responsible for addressing such processes. Identify and refer issues to other key processes such as risk management, billing audits or legal

All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits.

Wellness
Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more.

Why work at Presbyterian?
As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans.

About Presbyterian Healthcare Services
Presbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses.

Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.

Inclusion and Diversity
Our culture is one of knowing and respecting our patients, members, and each other. We capture this in our Promise and CARES commitments.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.