Grievance Coordinator
Location: Philadelphia, Pennsylvania
Description: AmeriHealth Caritas is presently looking of Grievance Coordinator right now, this vacancy will be situated in Pennsylvania. Detailed specification about this vacancy opportunity kindly see the descriptions. The Grievance Coordinator is responsible for ensuring that all problems, complaints and grievances, presented by Plan members or their representative are resolved in accordance with e! stablished policy and procedures, NCQA, and Federal/State guidelines. The Grievance Coordinator acts as a member advocate and independently communicates with Advocacy Groups, Community Representatives, Providers, Physicians, and all AHC departments including but not limited to Legal and Government Affairs, to interpret and enhance understanding of policies and procedures for complaints and grievances. Responsible to act as a facilitator within the team and demonstrate superior skill in dealing with members and providers. The Grievance Coordinator acts independently when representing the company at IBC appeals committee meetings and other meeting happening outside the company.
Principal Accountabilities:
Member Appeals
Assist member or provider, on behalf of the member, in filing a formal appeal. Reviews the information presented and clearly and accurately determines if a complaint or grievance is to be filed.
The Member Advocate which i! s a function of the grievance coordinator ensures that the mem! ber’s rights and access to care is maintained. They independently communicate with Internal and External departments including IBC at 1700 and 1900 Market Street, physicians, legal, government affairs.
Calls member, provider, physicians, attorney, etc. to explain the appeal process, the policy/ procedure related to the appeal and informs the member, provider etc. of their options including but not limited to not filing an appeal.
Gathers all necessary information for example, Letter of Medical Necessity, policies and documentation that describes the substance of the complaint or grievance and creates a file that will be distributed to the appeals panel.
Reviews information gathered to ensure that The Plan has followed their policy/ procedure and the regulatory requirements related to the appeal.
If the grievance coordinator determines that The Plan has not complied with all regulations related to the appeal, they notify the departments ! and an explanation is sent to that department informing the department of the appropriate action. The correction can include but are not limited to, rewriting the original outcome letter, keeping services in place or approving the service or medical equipment.
Actively seeks the involvement of the legal department or government affairs, whenever necessary, for clarification and supporting documentation.
Documents, in the appropriate computer system, all correspondence with a member and or a provider surrounding an appeal or issue. Thoroughly researches questions and issues in order to provide an accurate explanation.
Uses sound judgment and discretion when communicating findings and PHI related to the appeal. When necessary, will obtain authorization for release of sensitive and confidential information. Keeping in mind the minimal necessary rule.
The grievance coordinator attends 1st and 2nd level appeal committee meetings at IBC. The Ap! peal Committee is made-up of an IBC physician, manager, legal counsel a! nd a member of the health plan. The grievance coordinator must accurately present The Plan’s policies/ procedures and the regulations under which the company functions. Their testimony must be accurate and concise. The member, who has filed the appeal, and the member’s representative can attend the committee meeting. At the appeal meeting the member and their representative can ask the grievance coordinator questions about The Plan’s policies and procedures. The grievance coordinators statements are taken verbatim and become a permanent part of the appeal file. These files go to the Department of Health, Department of Insurance and Fair Hearing.
Tracks and reports case turn around time. Keeps abreast of all cases to ensure that the 30-day time limit for case resolution is meet on the 1st level and within 45 days for 2nd levels. Follows up, with The Plan, when this requirement is not met. Responsible for communicating NCQA requirements to appropriate personnel! involved in the member appeal process.
Keeps current with rules, regulations, policies and procedures relating to AHC Plans member benefits, member’s rights and responsibilities, and Complaints and Grievances.
Obtain a member’s written consent when needed. Accurately completes the documents needed to obtain the member’s consent and forwards documents to the member and the member representative including Legal Counsel.
Demonstrates a professional and courteous manner when communicating with others with the ability to clearly and accurately state agreed upon resolutions.
Demonstrates flexibility with ability to set priorities within established deadlines and time frames. Return calls to relevant agencies within prescribed time frames.
Demonstrates independence and initiative in completing assignments and follow-up on matters.
Demonstrates active listening, oral and written skills as related to documenting the substa! nce of the grievance. Accurately documents the outcome that the member ! or the provider on behalf of the member is seeking.
Demonstrates problem solving skills with the ability to analyze the information and draw conclusions.
Demonstrates attention to detail in the construction; completion of appeal files and dissemination of information.
Demonstrates ability to use the departmental database correctly adding information to assure accurate departmental reporting.
Demonstrates the ability to use the AHC shared drive to post and retrieve information.
Provides Complaint/Grievance training for The Plan’s staff in base unit and all supporting departments.
Demonstrates public speaking skills with emphasis on tone of voice, eye contact and the ability to deliver an accurate message and answer the question asked.
Maintains the performance standard of processing 95% of all member first level appeals within 30 days and second level appeals within 45 days of receipt, as defined in all regulat! ory and accreditation standards.
Follows up when compliance standards are not meet.
Performs other related duties and projects as assigned.
Adheres to AHC policies and procedures.
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If you were eligible to this vacancy, please email us your resume, with salary requirements and a resume to AmeriHealth Caritas.
Interested on this vacancy, just click on the Apply button, you will be redirected to the official website
This vacancy will be opened on: Tue, 17 Sep 2013 21:32:54 GMT
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