Appeals & Grievances Coordinator II

Summary:

The Appeals and Grievance (A&G) team manages all aspects of Appeals and Grievances processing including, but not limited to, intake, processing, notification, and compliance. This position, Appeal and Grievance Coordinator II, works as a member of the A&G team. Processing appeal and grievance requests in accordance  with standards established for accuracy, timeliness, productivity, client performance commitments, and regulatory requirements (e.g. State Regulations, Federal Regulations, Professional Accreditations). Utilize various business applications (e.g. MedAccess, MedResponse Appeals, FileNet, RightFax, SalesForce) to perform analysis, obtain information, and enter data as required for assigned duties. Utilize reasoning skills to evaluate appeal and grievance requests for appropriateness and ensure processes are followed accordingly. General knowledge of Microsoft Excel in order to assist in managing and generating reports for appeals and grievances metrics. Ability to multi- task and cross-train to process both appeals and grievances to assist with the weekend rotation schedule. Assist the Lead Appeals and Grievances Coordinator III in performing new employee training. Interact with internal and external customers as required. Work under general supervision, relying on work instructions, policies & procedures, and available company resources to perform the functions of the position efficiently and effectively.

Essential Functions and Responsibilities the following. Responsibilities include the following at a higher proficiency level than Appeals and Grievances Coordinator I.

• Evaluate and process Appeals and Grievances per establish work instructions and approved departmental documents.
• Perform and document outreach tasks (outbound calls or faxes) to obtain information necessary for processing Appeals and Grievances.
• Ensure Appeals and Grievances are finalized within the required turnaround time (TAT) in accordance with applicable laws and company policies.

• Provide and document required member and/or provider verbal notifications and review final written notifications for appropriateness.
• Provide excellent customer service and exhibit interpersonal communication skills (listening/verbal/written) when communicating with members and/or providers, collaborating with internal departments to address issues and inquires and when interacting with co-workers.
• Protect and maintain confidentiality and privacy of all member’s personal and health information in accordance with federal requirements and company policies.
• Must comply with company and department policies, procedures, rules and regulations.
• Must possess the ability to adapt to departmental changes as required for the needs of the business. Must be flexible with shift changes.

Additional Functions and Responsibilities include the following as Appeals and Grievances Coordinator II.

• Assisting management with the quality review program.
• Must be able to cross-train across the appeal and grievance task divisions.
• Managing and generating reports for appeals and grievances metrics.
• Assisting Appeals and Grievances Coordinator III with staff process training.
• Participating in the rotating weekend on-call schedule as needed.

Supervisory Responsibilities

This job has no supervisory responsibilities.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty as expected by management. The requirements listed below are representative of the knowledge, skill, and/or ability required.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience

High school diploma or general education diploma (GED); 3 years related experience; or equivalent combination of education and experience.

Previous Pharmacy Benefit Management experience preferred. Excellent proofreading abilities and data entry skills. Able to work independently with minimal supervision and/or in teams.

Computer Skills

To perform this job successfully, an individual should have knowledge of MS Office Suite.

Proficiency of knowledge of Microsoft Word and Microsoft Excel.

Certificates, Licenses, Registrations

Certified Pharmacy Technician and/or state licensure as a Pharmacy Technician required. Certified Pharmacy Technician Certification preferred.

Reasoning Ability

Ability to understanding, follow and apply detailed written and oral instructions. Ability to address problems involving a few variables in a standard process or requirement.

Mathematical Skills

Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals (basic math skills). Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.

Language Skills

Ability to read and comprehend basic instructions and compose routine correspondence. Ability to effectively present information one-on-one or in a group setting to customers, clients, and other employees of the organization.

Competencies

To perform the job successfully, an individual should demonstrate the following competencies:

Oral Communication

Speak clearly and persuasively in positive or negative situations. Listen and obtain clarification when needed. Responds well to questions.

Written Communication

Write clearly and informatively. Edit work for spelling and grammar.

Teamwork

Balance team and individual responsibilities. Exhibit objectivity and openness to others' view. Give and welcome feedback. Contribute to building a positive team spirit. Put the success of the team above own interests. Able to build morale and group commitments to goals and objectives. Support everyone’s efforts to succeed.

Organizational Support

Follow policies and procedures. Complete required tasks correctly and on time. Support organization's goals and values. Benefit organization through outside activities. Support affirmative action and respects diversity.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be provided to enable individuals with disabilities to perform the essential functions.