Description:
The Appeals and Grievances Clinical Coordinator is responsible for supporting the clinical team to ensure timely and accurate processing of cases. The clinical coordinator properly sets up case files for clinical review as needed and conducts general appeal research and filing including but not limited to organizational determination research, requesting member medical records, organizing documentation, preparing written summaries, scheduling the case, processing the review of the case, documentation of the appeal resolution and sending complete case files to external review organization as required by regulatory guidelines. The appeals and grievances may be related to all lines of business (Medicaid, Medicare, Commercial, etc.).
- Prepare cases for the clinical team by gathering documentation, loading evidence, and making calls to members and providers.
- Perform administrative activities including but not limited to generating and printing determination and authorization notification letters.
- Complete all associated data entry and authorization creation in the True care system.
- Correctly and completely preps completed case files for clinical review.
- Notifies team lead of identified patterns of appeals, claim errors, configuration issues or other systemic problems identified during appeal processing.
- Serves as a liaison in corresponding and communicating with providers and members as needed during appeal processing.
- Interacts with other departments including Contact Center Operations, Claims, DSE, and E&B to resolve member and provider appeals.
- Ensures appeals and grievances are categorized and processed within New York state and federal timeframes.
- Acts/Serves as a liaison between the Health Plan and Member, Members Family and Providers during appeal processing and outcome
- Prepare evidence packages, makes calls and draft letters as needed.
- Request denial files from delegated vendors and prepares cases for Clinical Specialist reviews.
- Maintains file integrity with regards to content and confidentiality.
- Participate in meetings.
- Additional duties as assigned.
Minimum Qualifications:
HS Diploma or GED
Preferred Qualifications:
- Bachelor’s degree
- Knowledge of related NY state and federal regulations highly desirable
- Proficiency in Microsoft Office required
- Knowledge of the New York state ART 44 PHL and federal regulatory environment
- Knowledge of claims payment process and claims data system (MHS)
- Ability to work both independently and as a team member
- Demonstrated ability to be deadline focused and to be flexible in order to adjust to priority changes