Job PurposeThe Appeals and Grievance Specialist I is responsible for ensuring professional handling of all member and provider reconsiderations in a timely and efficient way. The Specialist must possess broad understanding of all products and benefits as well as an understanding of regulatory requirements and timeframes. Specialists routinely interact with internal constituents about highly escalated issues.

Duties and responsibilitiesReceives and performs initial research on member and provider reconsiderationsCategorizes each reconsideration appropriatelyCompletes data entry and documentation requirements in multiple systemsActs as a liaison and coordinates functions with internal departments relative to the status of a member or provider reconsideration and the research needed to prepare the case for reviewPrepares and presents cases to the Director of Claims and any appropriate committeesResponsible for meeting all regulatory and department timelinesResponsible for researching and responding to legal requestsReviews and responds to appeals for timely submission for assigned thresholdsReviews and responds requests for retro prior authorizations for assigned thresholdsParticipates on team projects and special assignments as neededIdentifies systematic procedural issues and initiates action to resolve those issues, while maintaining documentation of all findings and actions takenMeets assigned deadlines and effectively communicates with all levels of staff and managementMaintains knowledge of provider contracts, plan policies and coverages, claim processing guidelines and systems, and an overall understanding of operational workflow processesWorks closely with other departments to gather informationAssists Appeals Resolution Clerk with clarification and maintenance of appeal triagingMaintains regular and predictable attendanceConsistently demonstrates compliance with HIPAA regulations, professional conduct, and ethical practiceMaintains work area in a clean and orderly condition and ensures safe operating conditions within area of responsibilityWorks to encourage and promote Company culture throughout the organization - waiting on this to be approvedOther duties as may be assignedQualificationsHigh School Diploma or GED requiredAssociates or Bachelor's degree preferred Two to three years of office experience with emphasis in customer service requiredKnowledge of ICD-10, CPT4 Coding, HCPCS and medical terminologyExperience with Word and Excel Effective interpersonal/communication skills are essentialCompetencies Ethics - Honest, accountable, maintains confidentialityReliability - The extent to which the employee can be depended upon to be available for work, do it properly, and complete it on time. The degree to which the employee is reliable, trustworthy, and persistent.Sense of Urgency - Meets deadlines, establishes appropriate priority, gets the job done in a timely mannerOrganization Skills - Information organized and accessible, maintains efficient workspace, manages time wellComputer Skills - Skilled with computers, takes advantage of new technology, learns new tools quickly, uses technology to enhance job performanceCommunication Skills - Possesses effective communication skills: oral, written, listeningProductivity - Manages workload, works efficiently, meets goals and objectivesInitiative - Takes action, seeks new opportunities, strives to see projects to completionPlanning & Organizing - Displays ability to effectively plan, organize and implement applicable tasks or projects in relation to established goals and objectivesQuality - Strives to eliminate errors, accurate work is a priority, seeks opportunities to improve product/servicesPhysical, Mental, Environmental & Working ConditionsModerate amount of walking, sitting, and writing. Moderate to significant amount of stress in meeting deadlines and dealing with day-to-day events in the execution of job duties. Needs flexibility and adaptability to change. Candidate must be self-disciplined and a self-starter and able to work independently with a flexible work schedule.

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