PacificSource Health Plans

  • Appeals and Grievances Coordinator

    Job Location US-OR-Eugene
    Job ID
    2018-373
    Type
    Regular Full-Time
    Hiring Pay Range
    $16.60 to $19 per hour
    # of Openings
    1
    Status
    Non-Exempt
  • Overview

    Position Overview:  Coordinate the internal appeals and grievances process by supporting entry of requests in timely manner to internal decision makers. Provide supporting compliance interpretation. Conduct in-depth research of regulatory, legal, contractual, and root cause of case specifics. Support member and provider experience.

    Responsibilities

    Essential Responsibilities:

    1. Oversee and coordinate all Appeal and Grievance activities ensuring response deadlines are met in accordance with applicable best practice, state and federal guidelines.
    2. Draft and provide acknowledgements by applicable method, to inquiries, grievances and appeals as required by regulations, PacificSource policy and department process standards.
    3. Accurately interpret benefit language from Member and Provider contract language as well as State and Federal Regulation materials.
    4. Prepare and provide response and resolution by applicable method to inquiries, grievances and appeals as required by regulations, PacificSource policy and department process standards.
    5. Coordinate and execute external review and hearing processes provided to members under applicable State and or Federal regulations.
    6. Perform thorough investigations utilizing critical thinking, and root cause evaluation methods to make informed and justified decisions on behalf of PacificSource.

     

    Supporting Responsibilities:

    1. Meet department and company performance and attendance expectations.
    2. Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
    3. Perform other duties as assigned.

     

    Qualifications

     

    Work Experience:  Mimimum of two years customer service, claims processing or health insurance industry experience required. 1+ year of technical writing and conflict resolution experience preferred.

     

    Education, Certificates, Licenses: High School Diploma required; Bachelor’s degree or equivalent experience preferred.

     

    Knowledge: Requires strong research, analytical and data entry skills.  Experience using Facets, Onbase, and other software packages used by PacificSource is strongly preferred.  Must have basic math skills, the ability to work under strict deadlines, and excellent organizational skills.

     

    Competencies

    Our Values

    • Adaptability
    • Building Customer Loyalty
    • Building Strategic Work Relationships
    • Building Trust
    • Continuous Improvement
    • Work Standards
    • Contributing to Team Success
    • Planning and Organizing.
    • 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 many 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.  Travel is required approximately 5% of the time.

     

    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, age.

     

    Apply

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