PacificSource Health Plans

  • Grievance & Appeals Analyst II

    Job Location US-OR-Bend
    Job ID
    2018-182 (A)
    Regular Full-Time
    Hiring Pay Range
    15.50 -17.00
    # of Openings
  • Overview

    Position Overview: Prepare, analyze, and process provider and member grievances, appeals, and claim disputes for all lines of business within timelines set by regulators.  Provide assistance and guidance to internal and external customers regarding grievance/appeals policies and procedures. Ensure customer satisfaction and help establish best practices.


    Essential Responsibilities:

    1. Manage the appeals/grievance process from beginning to completion, which entails researching complaints that initiate from a variety of sources, including members, providers, state/federal regulators, and others. Primary caseload will consist of member appeals/grievances. Provider appeals will be assigned on an as-needed basis, depending on workload and department need
    2. Gather comprehensive documentation from varied internal and external sources relevant to issue raised in grievance/appeal.
    3. Utilize various tools and resources including eligibility history, pre-authorization module, claims module and coverage documents to critically review appeals and grievances.
    4. Prepare information releases, as appropriate in relationship to grievances/appeals, consistent with HIPAA regulations and company protocol.
    5. Use critical thinking to investigate and correctly categorize cases and determine a course of review action and parties to contact. Accurately identify the different type of complaints.
    6. Accurately interpret benefit language from Evidence of Coverage documents, Medicare coverage policies, Medicare manuals and other literature, provider manuals, as well as state language from Oregon Administrative Rules. Determine which policies are appropriate for each individual case.
    7. Responsibilities exclude conducting any utilization or medical management review activities which require the interpretation of clinical information, but do include determining which medical information is relevant to the case, gathering, analyzing, and presenting it to medical reviewers. Responsibilities include conducting some non-clinical administrative reviews, as designated by G&A Manager.
    8. Document and maintain accurate grievance/appeal records with attention to detail. Modify authorizations as appropriate, route claims for timely reprocessing, and follow-up on resolutions as needed.
    9. Process correspondence to appealing party, timely and in accordance with federal/state regulations and established policies for all lines of business.
    10. Work independently under time pressure, and maintain company compliance by resolving and closing grievances/appeals within the timelines established by regulatory agencies and the plan, according to the processes established by the plan.
    11. Exemplify the team value of the organization by assisting other G&A analysts as needed, to maintain compliance and organization standards.
    12. Prepare member appeal files for Quality Improvement Organization, Independent Review Entity and administrative hearing levels. Prepare quality of care issues for further medical review.
    1. Provide superior customer service to internal staff, members, and providers in answering inquiries, gathering complaint information, or providing education. Understand and respect the cultural diversity of members.
    2. Educate and assist customers of Medicare and Medicaid appeal/grievance rights, benefits, and plan processes.
    3. Work collaboratively in an objective, professional, and diplomatic manner with all parties involved in a complaint.
    4. Communicate complex information related to medical decisions and G&A rules and regulations to internal and external customers.
    5. Route misdirected non-G&A issues to correct staff for timely and appropriate action.
    6. Provide updates to department manager regarding complaint activity and trends, offer suggestions for improvement.

    Supporting Responsibilities:

    1. Participate in meetings.
    2. Provide backup for other grievance and appeals staff as needed.
    3. Responsible for additional projects, including research/resolution/documentation of Complaint Tracking Module issues.
    4. Meet department and company performance and attendance expectations.
    5. Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
    6. Perform other duties as assigned.


    Work Experience: Minimum three years of experience in the healthcare or health insurance industry. Customer service experience helpful; active problem resolution experience preferred.


    Education, Certificates, Licenses: High school diploma or equivalent. Bachelor degree preferred.


    Knowledge: Strong knowledge of Medicare/Medicaid benefits, program structure and HIPAA laws/regulations. Strong understanding of grievance/appeal regulations for Medicaid and Medicare programs. Proven history of exceeding timely complaint resolution and accuracy requirements. Basic-intermediate proficiency in Microsoft Office Applications including Word and Excel and call tracking software, mainframe and medical management software. Basic-intermediate knowledge of medical terminology and medical coding. Knowledge of claims, authorization methodology, and provider networks. Excellent business writing skills, requiring minimal assistance with written grievance resolutions and Independent Review Entity documentation. Excellent time management and diplomatic skills.  Must be detail-oriented. Bilingual (Spanish) preferred.



    Our Values

    • Adaptability
    • Building Customer Loyalty
    • Building Strategic Work Relationships
    • Building Trust
    • Continuous Improvement
    • Contributing to Team Success
    • Planning and Organizing
    • Work Standards
    • We are committed to doing the right thing.
    • We are one team working toward a common goal.
    • We are each responsible for our 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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