Grievance & Appeals Dispute Specialist - Farmington, United States - ConnectiCare

ConnectiCare

Verified Company

Farmington, United States

1 week ago

Posted by:

Mark Lane

beBee recruiter

Description

Summary of Position

We are seeking a dynamic Grievance and Appeals Dispute Specialist who will be responsible for processing disputes submitted by contracted and non-contracted providers.

The types of correspondence handled by the individual will include, but is not limited to; correspondence, HQSI/ESMSEF appeals and Cotiviti disputes.

This individual will provide technical and administrative support to Grievance and Appeals dept. to ensure that departmental goals are met.

Roles and Responsibilities:

Facilitate the dispute review: submit appeal packet via UPS or dispute agent portal, as applicable.
Intake disputes and compile "dispute" packets for submission to either the DRA agent or Cotiviti
Review new dispute receipts to confirm request is valid and to identify the appropriate dispute agent. If request is invalid, notify the provider in writing with the reasons why the request is not valid.
Prepare disputes for external review, reviewing the previous appeal files as applicable and compiling all applicable documents to create the dispute packet.
Receive dispute decision, updating all applicable systems and notifying delegates as applicable
Review decision to confirm accuracy and append to the system
Document decisions in CAG; notify the Sr. Medical Clerk (SMC) to update the care management system as applicable.
If decision is overturned, the Dispute Specialist will reach out to claims to facilitate the effectuation of the decision.
Ensure timeframes are met and files are completed per G&A operational policies and procedures.
Monitor daily and weekly pending reports and CAG work list to ensure timely submission of files.
Classify/code CAG inquiries appropriately, entering all actions taken in investigation for auditing & reporting purposes.
Liaison with Claims to ensure determinations are effectuated within stringent timeframes.
Regular attendance is an essential function of the job.
Perform other duties as assigned or required.

Qualifications:

Associates degree
Additional experience/specialized training may be considered in lieu of educational requirements required

years' relevant, professional work experience required

Ability to work under pressure and deliver accurate and timely results required
Excellent communications skills (verbal, written, interpersonal) required
Working knowledge of Health Insurance processes required
Proficient with MS Office (Word, Excel, Powerpoint, Teams, Outlook, etc.) required
Excellent organizational, problem solving and analytical skills required

Additional Information