Coordinator, Appeals & Grievances
Posted on: November 22, 2022
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Headquartered in Philadelphia, AmeriHealth Caritas is a
mission-driven organization with more than 30 years of experience.
We deliver comprehensive, outcomes-driven care to those who need it
most. We offer integrated managed care products, pharmaceutical
benefit management and specialty pharmacy services, behavioral
health services, and other administrative services. Discover more
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Reporting to the Supervisor, Appeals and Grievances, this position
is responsible for the administrative tasks for coordination of
member and/or provider appeals; the analysis of claims and appeals;
and the review of medical management authorizations.
- Research and Investigate member and/or provider appeals and
grievance requests, includes review of UM/claim denial reasons,
contract/regulatory rules, benefits and documentation received on
- Outreach call(s) made to members/participants, providers and
/or member/participant representatives, to acknowledge receipt of
appeal/grievance and discuss intent of appeal/grievance. Explain
the appeal/grievance process including helping members understand
the outcome and implication of appeals decisions.
- Prepares case file (original denial, all information received
on appeal, medical records, etc.).
- Schedule participant/member for committee panel sends
scheduling letter if needed.
- Prepares, develops and presents written case summaries, if
needed and process dictates, for all adverse determination for the
purpose of conducting State Fair Hearings.
- Prepare and send cases files to other teams as needed (e.g.
legal, external appeals, state fair hearings, etc.).
- Communicates updates and status of outstanding member and
provider complaints/issues to management.
- Monitors to ensure that all problems with appeals/grievances
presented by plan members/participants are resolved in accordance
with established policies and procedures.
- Update and/or generate authorization updates requests, for
services that have been appealed.
- Maintains accurate, timely, and complete record of appeals and
grievances in the appeals system and documents, all correspondence
with a member/participant, representative and/or a provider,
related to an appeal or grievance issue.
- Maintains quality and compliance standards as dictated by the
state and federal entities
- Maintains contractual agreements with participating providers
related to appeals and grievances.
- Monitors caseload daily to ensure all cases are kept within
compliance; follows up and escalates when compliance standards are
- Actively seeks the involvement of the legal department or
compliance department, as necessary, for clarification and
supporting documentation by escalating issues to appeals and
- Obtain authorization for release of sensitive and confidential
- Keeps current with rules, regulations, policies and procedures
relating to Plan member benefits, members rights and
responsibilities, and Complaints and Grievances.
- Ensure case file is sent to appropriate committee for decision
making or example, internal committee/panel, independent review
organization, internal medical director - as process
- Provide support presenting cases and facilitating committee
meetings as needed.
- Send appeal to an independent review organization portal, for
those appeals that require an external match specialty
- Obtain data from multiple systems/vendors to ensure all
documentation needed for appeal is obtained, for e.g. PerformRX,
LTSS and other systems/vendors as needed.
- Collaboration with internal counterparts as needed to ensure
proper handling of the appeal e.g. UM team, medical directors,
claims, contact center, vendors as needed (e.g.
- Creates decision letter with detail description of the nature
of appeal / grievance including rational for the decision and
options for moving forward.
- Initiate and follow up on effectuations (um authorization
update/claim adjustment) for overturned appeals/grievances.
- This position requires the selected candidate to work out of
our campus at 220 Continental Drive, Suite 300, Newark, DE
- High School Diploma or GED required.
- 2+ years of experience in customer service and/or claims in a
managed care organization. Working knowledge of grievances and
- Knowledge of the basic health care industry, managed care
principles and medical terminology preferred.
- Proficiency and knowledge of Windows and Microsoft Office
applications (Word, Excel, and Outlook) and Adobe.
- Strong telephonic soft skills.
- Strong verbal and written communication skills.
- Demonstrated ability to multitask within a fast paced
- Demonstrated ability to quickly adapt to change and
reprioritize and successfully complete tasks within tight
timeframes for deliverables.
- Ability to resolve problems via research techniques and
critical thinking skills.
Keywords: Amerihealth, Newark , Coordinator, Appeals & Grievances, Other , Newark, Delaware
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