Lead/Supervisor, Grievance and Appeals-caVerda Healthcare, Inc has a contract with the Center of Medicaid and Medicare Services (CMS) and Texas Department of Insurance for a Medicare Advantage Prescription Drug (MAPD) plan for 2024. We are looking for a Grievance & Appeal, Lead/Supervisor to join our growing company with many internal opportunities.
Are you ready to join a company that is changing the face of health care across the nation? Verda Healthcare, Inc is looking for people like you who value excellence, integrity, caring and innovation. As an employee, you'll join a team dedicated to improving the lives of our Medicare members. Our vision incorporates value-based health care that works. We value diversity.
Align your career goals with Verda Healthcare, Inc and we will support you all the way.
Position Overview
The Grievance & Appeal Supervisor/Lead responds to written/verbal grievances, complaints, appeals and disputes submitted by members and providers: Review, analyze, research, resolve and respond to all types, in accordance with guidelines established by CMS and other regulatory agencies, where applicable, as well as internal policies. Will work with Clinical department regarding appeals related to Clinical policy. Work as an effective interface between internal and external customers. Maintain good member and provider relations. This position is part of Call Center. Job Responsibilities Review and evaluate appeal and grievance request to identify and classify member and provider appeals, hand-off to appropriate department for provider and clinical appeals; process member and provider complaints as appropriate to meet the CMS, State and Accreditation requirements.Determine eligibility, benefits, and prior activity related to claims, payment or service in question.Review research performed by operational areas to ensure the appropriate resolution to the appeal/grievance has been achieved.Conduct thorough investigations of all member and provider correspondence by analyzing all the issues involved and obtaining responses and information from internal and external entities.Perform comprehensive research related to the facts and circumstances of a member complaint, to include appropriate classification as a grievance, appeal, or both, in accordance with regulatory requirements.Research appeal files for completeness and accuracy and investigate deficiencies.Provide written acknowledgement of member and provider correspondence, prepare written responses to all member and provider correspondence that appropriately address each complaint's issues.Follow-up with responsible departments to ensure compliance.Responsible for making verbal contact with the member or authorized representative during the research process to further clarify, as needed.Ensure documentation requirements are met; create and document service requests to track and resolve issues.Provide all follow up documentation of outcome to practitioners, providers, and members.Responsible for the timely, complete, accurate documentation of the appeal and/or grievance both electronically, and hard copy.Enter and maintain critical data and records in support of Verda Health Plan business requirements, regulatory obligations timeframes.Track and trend outcomes and analyze data to provide reporting as required.Identify areas of potential improvement and provide feedback and recommendations to management on issue resolution.Serve as liaison with medical groups and network physicians to ensure timely resolution of cases.Perform other tasks, projects, etc. as needed or directed.Minimum Qualifications In lieu of degree, equivalent education and/or experience may be considered.3+ years of related, professional work experience required.2 years' experience in Medicare Managed Care preferred.Experience in a managed care/compliance environment preferred.Knowledge of medical terminology, provider reimbursement, medical coding, coordination of benefits and all types of medical claims required.Solid understanding of member and provider rights and responsibilities, particularly with appeals and grievance required.Familiarity with managed care state and federal regulations is required.Prior auditing experience preferred.Customer Service experience preferred.Proven leadership with staff, projects, and management.Strategic thinking abilities and analytical skills.Ability to clearly present written information and findings.Integrity and Trust.Customer Focus.Functional/Technical Skills.Written/Oral Communications.Critical/Analytical Thinker.Job Type: Full-time (Full Time Weekend rotation. Schedule to be determined.) 401(k)Health insuranceLife insurancePaid time offVision insuranceAbility to commute/relocate: Reliably commute or planning to relocate before starting work (Required)PHYSICAL DEMANDS Regularly sit/walk at a workstation in an office or cubicle setting. Must occasionally lift and/or move up to 25-50 pounds.
*Other duties may be assigned in support of departmental goals.
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