The primary purpose of this position is to handle member and provider grievances, standard appeals and claim disputes. This position will act as a key advocate and contact for HP members with general health care and accessibility concerns and inquiries on the various levels of the grievance and appeals process.
Determines which claim disputes meet acceptable claim dispute criteria, specifically screening for Untimely claims and Resubmissions; maintains a log, categorizes and tracks all received documents, notices, returned receipts; decides and responds to those appeals and claim disputes not meeting criteria with appropriate correspondence and routing. Assists in resolving member questions and concerns regarding the health care system in an effort to prevent the need for members to file formal grievances or appeals.
Enters all accepted appeals and claim disputes and its corresponding information into the CRM; creates and maintains case files, including appropriate review sheets for Medical Review and/or Claim Review according to policy, AHCCCS, HCG, and CMS regulations; updates CRM for ongoing cases with responses from reviewers. Assesses individual cases and documents in various CRM programs for pertinent information for referral and/or transmission to co-workers.
Ensures all appeals and claim disputes are acknowledged, by official correspondence, within AHCCCS, HCG, and CMS contractual timelines; protects the confidentiality of member information and other information. Facilitates, communicates and accepts input regarding member and provider appeal information from appropriate individuals that would include employees, providers, Medical Director, Plan Administrator, RNs, Risk Management, attorneys, AHCCCS, HCG, CMS and others.
Responds to all incoming phone calls, researches and resolves member and provider questions and concern regarding grievances, appeals and claim disputes. Opens, reviews, researches (if necessary), date stamps and routes or responds to all incoming mail. Responds in an expedient manner that is consistent with the mission and values of UAHN and in support of related regulations and policies and procedures to member, staff and physician grievances, appeals and claim disputes with minimal supervision.
Creates and submits all resolution and extension correspondence, utilizing appropriate Arizona Revised Statues, Arizona Administrative Code, Code of Federal Regulations, and other supporting regulatory policies and statutes for all UAHP managed plans. Self-audits daily to ensure compliance with regulatory requirements.
Recognizes, facilitates and gathers relevant medical records, coding and claim documentation that is required for the reviewers to fully investigate grievances, appeals, and claim disputes. Responsible for trouble shooting, identifying, and resolving special handling requirements related to grievance and appeal issues.
Reports at Grievance/Appeals meetings, as appropriate, all incoming, attended and scheduled State Fair Hearings.
Works internally with other departments in order to facilitate timely responses and inquiries, and assists with workgroups as requested. Provides technical expertise to other departments regarding grievances, appeals and claim disputes.
High school diploma/GED or equivalent working knowledge. Two years of work experience in health care related field or experience managing projects/initiatives, or an equivalent combination of education and experience.
Knowledge of AHCCCS, HCG and/or CMS regulations.Knowledge of MS Word, Excel and Microsoft Office Suite required. Knowledge of Medical terminology, claims processing guidelines, and CRM & IDX. Knowledge of grievance, appeal and claim dispute processes.
Strong interpersonal, organizational and problem solving skills. Strong oral and written communication skills required. Ability to work independently ensuring all deadlines/timelines are met and to work with various levels of healthcare professionals. Ability to be flexible and work on a variety of projects simultaneously under tight time constraints.Strong analytical, critical-thinking and time management skills. Strong organizational skills and ability to prioritize multiple tasks daily. Ability to quickly identify, summarize and present (verbally and orally) options to issues which may arise, and to consistently meet and exceed regulatory reporting requirements for all lines of business.
Additional related education and/or experience preferred.
Internal Number: 250799
About Banner Health
You want to change the health care industry – one life at a time. You belong here. You’re excited to be part of the dramatic changes happening in the health care field. In fact, you thrive on change. But you also understand that excellent, compassionate patient care is the true measure of the success of these changes. You belong at Banner Health. Our award-winning, comprehensive health system includes 23 hospitals in seven western states, primary care health centers, research centers, labs, a network of physician practices and much more. Throughout our system, skilled, compassionate professionals use the latest technology to change the way care is provided. If you’re looking to be a key contributor to a forward-looking organization, you’ll experience a wide variety of professional advantages: •Our vision for changing the future of health care gives you the opportunity to leverage your abilities to achieve something historic. •Our expansive system offers you an unmatched variety of clinical settings – from large urban trauma center to small rural hospital, ambulatory to home health. Our system also includes hospitals specializing in cancer, heart health and pediatrics. •Our many loc...ations also translate into a broad selection of exciting and rewarding lifestyle options – from the big city to the wide-open spaces. •Our commitment to healthcare innovation means you always have the latest technologies at your fingertips to help you provide the finest care possible. •The size, success and growth of our system provide you with the stability and options to pursue your desired career path. •Our competitive compensation and comprehensive benefits offer you options to complement your unique needs.