PacificSource Health Plans

Grievance & Appeals Support

US-OR-Bend
Job ID
2017-362A
Type
Regular Full-Time
Hiring Pay Range
$13.29-$16.60
# of Openings
1
Status
Non-Exempt

Overview

Provide assistance to Grievance & Appeal team in maintaining records and processing grievances and appeals for all lines of business within the timelines set by regulators.  Provide assistance and guidance to internal and external customers regarding grievance/appeals policies and procedures. Ensure member satisfaction and help establish best practices

Responsibilities

  1. Process intake of appeals and grievances into the department’s tracking database.
  2. Monitor incoming faxes, route to appropriate staff in a timely manner and file in accordance with plan processes.
  3. Route incoming grievances and appeals to designated analysts for further action in a timely manner, compliant with timelines established by regulatory agencies and the plan.
  4. Route misdirected non-G&A issues to correct staff for timely and appropriate action.
  5. Assist in gathering comprehensive documentation as needed, from varied internal and external sources relevant to issue raised in grievance/appeal.
  6. Assist team in documenting/updating cases in tracking database and other member applications, maintain accurate grievance/appeal records.
  7. Book administrative law hearings as scheduled by the Office of Hearings, including booking of attendees and conference rooms. Ensure all relevant material is complete.
  8. Maintain filing system and ensure all case files are stored timely and accurately in the appropriate applications.
  9. Maintain office supply inventory for the department.
  10. Provide education and follow-up as needed to plan staff, members, and providers.
  11. Work collaboratively in an objective, professional, diplomatic manner with all parties involved in a complaint.
  12. Communicate complex information related to G&A rules and regulations both verbally and in writing to internal and external customers.
  13. Provide updates to department manager regarding appeal activity and trends.

 

Supporting Responsibilities:

  1. Assist with and participate in meetings as assigned.
  2. Provide backup for other G&A staff as needed.
  3. Meet department and company performance and attendance expectations.
  4. Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
  5. Perform other duties as assigned.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Qualifications

Work Experience: Minimum one year experience in the healthcare, social service or health insurance industry.

 

Education, Certificates, Licenses: High school diploma or equivalent.

 

Knowledge: Basic proficiency in Microsoft Office Applications including Word and Excel and call tracking software, mainframe and medical management software. Basic knowledge of medical terminology, medical coding and claims/authorization methodology, Medicare/Medicaid program structure and HIPAA laws/regulations. Ability to work under time pressure.

 

Competencies

Our Values

  • Building Customer Loyalty
  •  Building Strategic Work Relationships
  • Contributing to Team Success
  • Planning and Organizing
  • Continuous Improvement
  • Adaptability
  • Building Trust
  • Work Standards

 

 

  • We are committed to doing the right thing.
  • We are one team working toward a common goal.
  • We are each responsible for customers’ experience.
  • We practice open communication at all levels of the company to foster individual, team and company growth.
  • We actively participate in efforts to improve our communities,internal and external.
  • We encourage creativity, innovation, continuous improvement and the pursuit of excellence.

 

 

Environment: Work inside in a general office setting with ergonomically configured equipment.

 

Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions.  Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

 

Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.

 

 

PacificSource is an equal opportunity employer.  All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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