Position Purpose: Analyze and resolve verbal and written claims and authorization appeals from providers and pursue resolution of formal grievances from members.
Education/Experience: High school diploma or equivalent. Associate’s degree preferred. 2+ years grievance or appeals, claims or related managed care experience. Strong oral, written, and problem solving skills.
• Gather, analyze and report verbal and written member and provider complaints, grievances and appeals
• Prepare response letters for member and provider complaints, grievances and appeals
• Maintain files on individual appeals and grievances
• May coordinate the Grievance and Appeals Committee
• Support the pay-for-performance programs, including data entry, tracking, organizing, and researching information
• Assist with HEDIS production functions including data entry, calls to provider’s offices, and claims research.
• Manage large volumes of documents including copying, faxing and scanning incoming mail
EEO:
“Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of – Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.”
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Story Behind the Need
- What is the purpose of this team?
- Describe the surrounding team (team culture, work environment, etc.) & key projects.
- Do you have any additional upcoming hiring needs, or is this request part of a larger hiring initiative?
- The Grievance and Appeals Coordinator will be responsible for processing all appeals in accordance with NCQA quality standards and within regulatory timeframes.
- All members of the G&A team work remotely and do well maintaining standards and a productive, collaborative, and psychologically safe work environment.
- Currently, I am looking to fill one position to accommodate an increase in volume for the Ambetter line of business.
Typical Day in the Role
- Walk me through the day-to-day responsibilities and a description of the project (Outside of the Workday JD).
- What are performance expectations/metrics?
- What makes this role unique?
- CAMERAS ON FOR TEAM MEETINGS AND 1ON1s
- The work day is spent acknowledging and resolving member appeals within established turnaround times. Member facing team but providers may reach out to request appeals on members behalf. Appeals mainly via fax but may come through phone or email
- Maintain or exceed 98% compliance rate for all appeal files while meeting daily productivity benchmark of 8-10 cases per day based on the volume.
- This role ensures regulatory compliance by managing time-sensitive member appeals in accordance with CMS and state guidelines. It requires deep knowledge of managed care processes, strong analytical and communication skills, and the ability to coordinate across departments to resolve complex issues impacting member care and health plan operations.
Candidate Requirements
Education/Certification
Required: High school diploma or equivalent
Preferred: Associate’s degree preferred
Licensure
Required: N/A
Preferred: N/A
Years of experience required: At least 1+ years’ experience with Grievance & Appeals. Regulatory knowledge (CMS, Medicaid, NCQA)
Disqualifiers: Lack of health care or managed care experience, poor attention to detail, weak communication skills, inexperience with grievance and appeals or UM related roles, lack of critical thinking and problem-solving skills, and poor time management.
Additional qualities to look for: Previous grievance and appeals or UM prior authorization experience, regulatory knowledge, critical thinking/problem solving with independent work, organizational skills, adaptability, and professionalism. This is a production environment. Interpersonal skills. Technology proficiency.
- Top 3 must-have hard skills stack-ranked by importance
1
Formal written communication; accuracy with data entry and tracking/ independent work
2
Prioritization and time management skills
3
Regulatory knowledge (CMS, Medicaid, NCQA)
Candidate Review & Selection
- Shortlisting process
- Candidate review & selection
- Interview information
- Onboard process and expectations
Projected Manager Candidate Review Date:
1-2 days post shortlisting ASAP
Type of Interviews:
Teams CAMERA ON
Required Testing or Assessment (by Vendor):
Computer literacy test
Next Steps
- Additional background check requirements (List DFPS or other specialty checks here)
NA
- Do you have any upcoming PTO?
- Colleagues to cc/delegate
Lamar Watson
- Are there any training requirements (time off, alternate schedule, etc.)?
