Appeals and Grievance Coordinator

Location Address:

Compensation Pay Range:

Summary:

Responsibilities:

Responsible for the daily coordination of activities within the Appeals & Grievance Department. Assists in assuring that all compliance timelines are met. Acts as a mentor, a resource as well as a team lead in addressing complaints and appeals/grievances. Interacts with regulatory agencies, patients, members, stakeholder, leaders, and internal departments and staff. Function as primary contact for various regulatory bodies who maintain oversight of the administration of complaints, appeals, and grievances. Provides feedback and process improvement recommendations to appropriate quality committees based on analysis and trending of complaint data and appeal/grievance data. Responsible for identification of trends and meeting goals

Some key responsibilities include:

• Coordinates daily activities of the Specialists providing growth opportunities and mentoring to each team member. Responsible for oversight of work production of Specialists, and review of decisions made by Specialists. Escalates appropriate issues for further involvement.
• Coordinates, investigates, and resolves customer complaints and appeals/grievances. Independently identifies issues needing resolution. Responsible for making decisions in cases of dispute that were not decided or resolved.
• Responsible for reviewing research and decisions by other business units, organizational department heads, and other departments and conducting more detailed investigative research into the matter, meet as required in order to achieve the best outcome for the complainant, grievant/appellant while best representing the interests of Presbyterian.
• Works closely with Legal/Risk Management, Medical Directors, Medical Staff, department leads, department Directors, regulatory representatives, and outside professional consultants to achieve consistent outcomes in cases of complaints, appeals and grievances.
• Assists in maintaining compliance with all applicable compliance standards, meeting goals relating to customer and provider satisfaction and providing excellent levels of service to all internal and external customers.
• Functions as primary contact for various regulatory bodies who maintain oversight of the administration appeals and grievances.
• Required to compose correspondence to all regulatory agencies in compliant format, to include corrective action plans, follow up on cases, and reports as requested by regulators. Will attend and represent the organization at meetings with regulators as the need arises.
• Required to communicate in writing with customers or their representatives, health plan members, providers or their designated representative; Responsible for application of contract language from contracts in correspondence.
• Ensure written correspondence is reviewed for regulatory statutes and requirements for a multitude of customer types and product line specified requirements. Ensure responses to complainants and grievant are within policy timelines as defined by the appropriate regulatory body.

Qualifications:

• High School Diploma or GED
• Five years customer service experience required.
• Three years experience in health care or insurance setting, of which one year must have been in interpretation of regulations for complaint, grievance or appeal processing.
• Bachelors degree preferred in healthcare related field.
• Preferred experience in claims processing, patient financial services, utilization management, in a in an HMO/MCO/MSO or health insurance environment

All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits.

Wellness
Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more.

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.

About Presbyterian Healthcare Services
Presbyterian exists to improve the health of patients, members, and the communities we serve. We are 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 1600 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.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.