Appeals and Grievance Coordinator

Now hiring a Appeals and Grievance Coordinator

Responsible for the daily coordination of activities within the Appeals & Grievance Department. Assists in assuring that all compliance timelines are met. Acts as a mentor, a resource as well as a team lead in addressing complaints and appeals/grievances. Interacts with regulatory agencies, patients, members, stakeholder, leaders, and internal departments and staff. Function as primary contact for various regulatory bodies who maintain oversight of the administration of complaints, appeals, and grievances. Provides feedback and process improvement recommendations to appropriate quality committees based on analysis and trending of complaint data and appeal/grievance data. Responsible for identification of trends and meeting goals

How you belong matters here.

We value our employees' differences and find strength in the diversity of our team and community.

At Presbyterian, it's not just what we do that matters. It's how we do it - and it starts with our incredible team. From Information Technology to Food Services and beyond, our non-clinical employees make a meaningful impact on the healthcare provided to our patients and members.

Why Join Us

Full Time - Exempt: Yes
• Job is based at Rev Hugh Cooper Admin Center
• Remote work from home: this job is intended to be conducting in the state of New Mexico.
• Work hours: Days
• Benefits: We offer a wide range of benefits including medical, wellness program, vision, dental, paid time off, retirement and more for FT employees

Ideal Candidate:

• Bachelors degree preferred in healthcare related field.
• Five years customer service experience required.
• Three years experience in health care or insurance setting, of which one year must have been in interpretation of regulations for complaint, grievance or appeal processing

• High School Diploma or GED
• Five years customer service experience required.
• Three years experience in health care or insurance setting, of which one year must have been in interpretation of regulations for complaint, grievance or appeal processing.
• Bachelors degree preferred in healthcare related field.
• Preferred experience in claims processing, patient financial services, utilization management, in a in an HMO/MCO/MSO or health insurance environment

• Coordinates daily activities of the Specialists providing growth opportunities and mentoring to each team member. Responsible for oversight of work production of Specialists, and review of decisions made by Specialists. Escalates appropriate issues for further involvement.
• Coordinates, investigates, and resolves customer complaints and appeals/grievances. Independently identifies issues needing resolution. Responsible for making decisions in cases of dispute that were not decided or resolved.
• Responsible for reviewing research and decisions by other business units, organizational department heads, and other departments and conducting more detailed investigative research into the matter, meet as required in order to achieve the best outcome for the complainant, grievant/appellant while best representing the interests of Presbyterian.
• Works closely with Legal/Risk Management, Medical Directors, Medical Staff, department leads, department Directors, regulatory representatives, and outside professional consultants to achieve consistent outcomes in cases of complaints, appeals and grievances.
• Assists in maintaining compliance with all applicable compliance standards, meeting goals relating to customer and provider satisfaction and providing excellent levels of service to all internal and external customers.
• Functions as primary contact for various regulatory bodies who maintain oversight of the administration appeals and grievances.
• Required to compose correspondence to all regulatory agencies in compliant format, to include corrective action plans, follow up on cases, and reports as requested by regulators. Will attend and represent the organization at meetings with regulators as the need arises.
• Required to communicate in writing with customers or their representatives, health plan members, providers or their designated representative; Responsible for application of contract language from contracts in correspondence.
• Ensure written correspondence is reviewed for regulatory statutes and requirements for a multitude of customer types and product line specified requirements. Ensure responses to complainants and grievant are within policy timelines as defined by the appropriate regulatory body.
• Maintains knowledge of claims processing, contractual specifics, plan changes, and regulatory guideline updates. Responsible to know regulatory requirements and guidelines related to complaint management, grievance and appeals.
• Review, coordinate detailed research, prepare the chronological evidence documents, and present the facts of each case that proceeds to further internal or external review including External Review Hearings and Fair Hearings in order to explain the rationale for all decisions and negotiate a resolution.
• If the issue is one involving the health plan, must prepare and submit the chronological evidence and rationale for all adverse determinations upheld by the Appeals & Grievance committee for Medicare appeals cases to the CMS contracted external entity.
• Has a key role in representation of the Appeals & Grievance Department and its functions with all oversight audits from regulators. Must be prepared to be interviewed, audited or review work products at all times, when such reviews or interviews are requested.
• Represents the organization in audits of all sub-contractors pertaining to the handling and reporting of complaints, grievances and appeals. Sits on committees to work collaboratively with subcontractors to achieve compliance with regulations relating to grievances and appeals.
• Provides representation at internal and external meetings, demonstrations, staff training, and presentations of complaint related information. Conducts team meetings to facilitate team building, consistent training and overall growth and support of the team.
• Documents and categorizes all issues processed. Responsible for file maintenance and internal audits, produces and maintains required tracking and trending reports of all complaints, appeals and grievances in accordance with regulatory requirements.
• Responsible for supporting the organization s overall quest for process improvement, identifying areas that are in need of evaluation and redesign. Develop process to identify, trend and report types of complaints and ongoing or systemic problems. Provide feedback and process improvement recommendations to appropriate quality committees and various departments based on analysis and trending of complaint data.

All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits.

Wellness
Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more.

Why work at Presbyterian?
As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans.

About Presbyterian Healthcare Services
Presbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses.

Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.