Job Summary

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. PresentsMember appeals to the Plan Medical Staff and Center for Medicare/Medicaid Services contracted reviewer.

Job Duties

• 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.
• Makes suggestions for policies and procedures covering all regulatory and accreditation standards for all lines of business.

Work is typically performed in an office environment. ​​Ability to travel is required. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.

*Relevant experience may be a combination of related work experience and degree obtained (Associate’s Degree = 2 years; Bachelor’s Degree = 4 years).

Position Details

Education

High School Diploma or Equivalent (GED)- (Required)

Experience

Minimum of 5 years-Relevant experience* (Required)

Certification(s) and License(s)

OUR PURPOSE & VALUES: Everything we do is about caring for our patients, our members, our students, our Geisinger family and our communities. KINDNESS: We strive to treat everyone as we would hope to be treated ourselves. EXCELLENCE: We treasure colleagues who humbly strive for excellence. LEARNING: We share our knowledge with the best and brightest to better prepare the caregivers for tomorrow. INNOVATION: We constantly seek new and better ways to care for our patients, our members, our community, and the nation. SAFETY: We provide a safe environment for our patients and members and the Geisinger family We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners. Perhaps just as important, from senior management on down, we encourage an atmosphere of collaboration, cooperation and collegiality. We know that a diverse workforce with unique experiences and backgrounds makes our team stronger. Our patients, members and community come from a wide variety of backgrounds, and it takes a diverse workforce to make better health easier for all. We are proud to be an affirmative action, equal opportunity employer and all qualified applicants will receive consideration for employment regardless to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or status as a protected veteran.

We are an Affirmative Action, Equal Opportunity Employer Women and Minorities are Encouraged to Apply. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or their protected veteran status.

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