What are the responsibilities and job description for the Appeals and Grievances - Health Plan position at TotalMed?
Description:
This position serves as a clinical and administrative subject matter expert for Part C and Part D grievance and appeal functions; investigating and identifying member, provider and/or claim processing appeals and customer service grievances issues; and ensuring that investigation, resolution and responses are processed promptly in accordance with CMS requirements and timelines
Qualifications
Associate’s Degree in a healthcare field of study or Nursing Diploma, Licensed Practical Nurse or Registered Nurse with a current, active, unrestricted nursing license in the state of Arizona, 1-3 years prior work experience in a managed care environment., 5 years of work experience with CMS member services, prior authorizations, appeal and grievance, or claims functions
Responsibilities
Maintains a current knowledge of CMS rules and regulations relating to the grievance and appeal processes., Participates in CMS and other audits and related activities as required., Coordinates investigation and resolution of complex grievance and appeal issues, Performs all assigned functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards., Provides an excellent service experience to internal and external customers by consistently demonstrating our core and leadership behaviors each and every day., Perform all other duties as assigned.
Salary : $44