Appeals & Grievance Specialist
Full Time
Albuquerque, NM 87113
Posted
Job description
Overview:
Type of Opportunity: Full Time
FTE: 1.000000
Exempt: No
Work Schedule: Days Qualifications:
Learn more about our employee benefits:
https://www.phs.org/careers/employee-benefits/Pages/default.aspx
Why work at Presbyterian?
Presbyterian's story is really the story of the remarkable people who choose to work here. The hard work of our physicians, nurses, employees, board members and volunteers grew Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system that serves more than 875,000 New Mexicans.
About Presbyterian Healthcare Services
Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.
About Our Regional Delivery System
We are part of New Mexico's history - and committed to its future. That is why we will continue to work just as hard and care just as deeply to serve New Mexico for years to come.
About New Mexico
Varied landscapes bring filmmakers here from around the world to capture a slice of the natural beauty New Mexicans enjoy every day. Our landscapes are as diverse as our culture - from mountains, forests, canyons, and lakes, to caverns, hot springs and sand dunes.
New Mexico offers endless recreational opportunities to explore and enjoy an active lifestyle. Venture off the beaten path, challenge your body in the elements, or open yourself up to the expansive sky. From hiking, golfing and biking to skiing, snowboarding and boating, it's all available among our beautiful wonders of the west.
Responsible for responding to verbal and written complaints, grievances, and requests for appeals that involve complex matters. Responsible for performing comprehensive research to clarify facts and circumstances. Able to identify the root cause for an issue. Assure that customers and health plan providers receive exceptional service when acknowledging, discussing, documenting or responding to their issue of dissatisfaction. Makes initial decision regarding resolution of complaints, grievances or appeals based on completed research. Responsible for making sure issues are categorized and can be reported to internal stakeholders, oversight committees and regulatory agencies. Able to act as a member advocate in each case, comparing the grievant/appellants issues with the organization s documented facts
Type of Opportunity: Full Time
FTE: 1.000000
Exempt: No
Work Schedule: Days
High School education or G.E.D. equivalent required. Associates Degree preferred. Three years experience in a customer service setting required of which one year in a health care environment is preferred. Experience in managed care field such as Claims or Member Services strongly preferred. Experience with healthcare databases is preferred
Responsibilities:
- Perform research related to the facts and circumstances of a member and provider complaint, appeal, or grievance.
- Gathers necessary documents (from internal and external resources) related to an appeal, grievance or complaint to develop a complete file. Gathers information from clinical sources, medical records, chart reviews, admitting records, patient financial records, and from subject matter experts in order to research the facts of all complaints, grievances and appeals. Uses available documentation including DART, provider manuals, member contracts and online policies and procedures to support accurate and consistent decisions relating to claims payment, authorizations, contractual issues, servicing and care standards, and all other operational aspects of the organization.
- Required to document the substance of each complaint, grievance or appeal case according to legal requirements. Responsible for making direct verbal contact with members and providers who have filed a complaint, grievance or appeal during research process in order to fully document the issue. Required to communicate in writing with customers, members, providers or designated representative; using the regulatory compliant format on all issues both for acknowledgment and resolution. All written correspondence must be reviewed for regulatory statutes and requirements for all customer types. Must be able to professionally articulate orally and in writing an understanding of complex issues and detailed action plans.
- Responsible for reviewing research performed by other referral sources, department heads, other departments and conduct more detailed investigative research into the matter to resolve issues of complaint, grievance or appeal.
- Responsible for making decisions in cases of dispute that were not decided or resolved by other referral sources or departments. Such decisions will be made using policy and guidelines, detailed research and applying a standard of reasonableness, considering all actions previously taken by others.
- Responsible for application of contract language from member contracts, provider contracts and employer contracts in researching and deciding outcomes.
- Works closely with Legal/Risk Management, Medical Staff, Medical Directors, Department Directors, regulatory representatives, and outside professional consultants to achieve consistent outcomes in cases of complaints, grievances and appeals.
- Presents completed research file along with recommendation and decision for resolution to the appropriate Appeals and Grievance Coordinator within the time period necessary to remain in compliance with regulatory requirements for appeals, grievances or complaints.
- Responsible for file and documentation preparation of all cases that proceed to further internal or external review and for regulatory and oversight audit activities.
- Responsible for communicating complaint resolutions/decisions to grievant, legal representatives and providers both telephonically and in writing.
- Responsible to know regulatory requirements for member and provider complaint, grievance and appeals processing.
- Logs complaints, grievances, and appeals issues, and identifies trends. Must be proficient with database entry and categorization of issue type, receipt date, timeframe for acknowledgement and resolution processing.
- Required to document or phone log all issues processed and categorizes accordingly.
- Monitor effectiveness of resolutions/outcomes as a result of the complaint/grievance/appeal process.
- Assists in the development of process improvement functions that result from complaints, appeals and grievance processing.
- Identify errors and inconsistencies that require revisions to guidelines or system modifications, bringing errors to the attention of appropriate personnel in each affected department or quality committee responsible for addressing such processes. Identify and refer issues to other key processes such as risk management, billing audits or legal
We offer more than the standard benefits!
Presbyterian employees gain access to a robust wellness program, including free access to our on-site and community-based gyms, nutrition coaching and classes, wellness challenges and more!
Learn more about our employee benefits:
https://www.phs.org/careers/employee-benefits/Pages/default.aspx
Why work at Presbyterian?
As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans. For our employees, we offer a robust wellness program, including free access to our on-site and community-based gyms, nutrition coaching and classes, wellness challenges and more.
Presbyterian's story is really the story of the remarkable people who choose to work here. The hard work of our physicians, nurses, employees, board members and volunteers grew Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system that serves more than 875,000 New Mexicans.
About Presbyterian Healthcare Services
Presbyterian Healthcare Services exists to improve the health of patients, members and the communities we serve. We are a locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1,600 providers and nearly 4,700 nurses.
Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.
About Our Regional Delivery System
Presbyterian's Regional Delivery System is a network of six hospitals and medical centers throughout rural New Mexico including locations in Clovis, Espanola, Ruidoso, Santa Fe, Socorro and Tucumcari. Our regional facilities are home to more than 1,600 clinical and non-clinical employees who help make Presbyterian the state's largest private employer with nearly 14,000 statewide employees. With a variety of services ranging from general surgery to pediatrics to heart and cancer care, our regional employees are proud to provide close-to-home care for their communities.
We are part of New Mexico's history - and committed to its future. That is why we will continue to work just as hard and care just as deeply to serve New Mexico for years to come.
About New Mexico
New Mexico continues to grow steadily in population and features a low cost-of living.
Varied landscapes bring filmmakers here from around the world to capture a slice of the natural beauty New Mexicans enjoy every day. Our landscapes are as diverse as our culture - from mountains, forests, canyons, and lakes, to caverns, hot springs and sand dunes.
New Mexico offers endless recreational opportunities to explore and enjoy an active lifestyle. Venture off the beaten path, challenge your body in the elements, or open yourself up to the expansive sky. From hiking, golfing and biking to skiing, snowboarding and boating, it's all available among our beautiful wonders of the west.
AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.
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