Coordinator, Grievance and Appeals

Navitus Health Solutions is seeking a Coordinator, Grievance and Appeals to join our teams!

This is an onsite role located at our Appleton, WI office.

The Navitus Grievance and Appeals process is an essential function to Navitus' compliance with CMS regulations, accrediting body standards, other applicable regulatory requirements, and member expectations. The Navitus Grievance and Appeals department serves as the central repository for all complaints received by Navitus and all appeal requests where the responsibility has been delegated to Navitus. The Navitus Grievance & Appeals Coordinator serves to administrate the Navitus Grievance and Appeals processes as outlined by Client/Plan Sponsors, departmental policies and procedures, and regulatory standards. Coordinator, Grievance and Appeals serves as a liaison for Navitus members, prescribers and pharmacies regarding complaints or appeals related to denied pharmacy claims, membership and benefit issues, reimbursements and quality of care or service. Coordinator, Grievance and Appeals is responsible for presentation of the member appeals as required to the Medical Director, Center for Medicare/Medicaid Services, contracted reviewer, Client, and/or the contracted external review agency in accordance with applicable laws, organization policies, and regulatory requirements. Thorough research, documentation, and corrective action planning must be established for each respective case and effectuation completed in accordance with existing regulations, policies, and standards.

Is this you? Find out more below!

How do I make an impact on my team?

Administrate Standard and Expedited Appeals Processes as outlined in Client/Plan Sponsor Member Handbook and in compliance with applicable accrediting body standards, CMS and other state or federal regulatory requirements. Strict adherence to turn-around time and quality of documentation standards established in accordance with regulatory standards is required.
• Act as the primary investigator and contact person for member, prescriber or pharmacy grievances and appeals, which includes sending the appropriate acknowledgement of the grievance/appeal per policy, educating the member and/or member representative about the grievance/appeal, gathering all pertinent and relevant information regarding the grievance/appeal, notifying the appropriate parties of the resolution per policy and ensuring that all internal processes are completed to resolve the issue
• Gather and provide documentation and research outcomes within required timeframes to Clients/Plan Sponsors who manage their own appeals
• Thoroughly document all action taken on behalf of the member to resolve the grievance/appeal
• Prepare and deliver statistics for required reporting
• Participate in audits, including document preparation and participation in on-site or remote audits, as a subject matter expert
• Abiding by HIPAA regulations and confidentiality requirements; document, research and review member complaints, involving quality of care or quality of service with appropriate clinical and/or other department staff
• Educate and monitor compliance with complaint and appeal procedures in such departments as the call center and prior authorization
• Audit and provide oversight of upstream and downstream processes impacting complaints and appeals
• Other duties as assigned

What our team expects from you?

• High School Diploma or equivalent required. 2 years post high school education or bachelor's degree preferred. CPhT certification or ability to obtain desired and preferred
• 2-3 years of managed care and/or insurance background in addition to a strong knowledge of CMS coverage determination and redetermination processes preferred
• Experience with CMS and/or NCQA audits strongly desired
• Proven success in documenting case files and managing multiple cases within requires timeframes desired
• Participate in, adhere to, and support compliance program objectives
• The ability to consistently interact cooperatively and respectfully with other employees

What can you expect from Navitus?

• Top of the industry benefits for Health, Dental, and Vision insurance
• 20 days paid time off
• 4 weeks paid parental leave
• 9 paid holidays
• 401K company match of up to 5% - No vesting requirement
• Adoption Assistance Program
• Flexible Spending Account
• Educational Assistance Plan and Professional Membership assistance
• Referral Bonus Program - up to $750!

#LI-Onsite