Grievance & Appeals Coordinator With RN, LVN, or LPN
Job Description
Our client, a well-funded and well-established non-profit providing pension and health benefits to entertainment industry professionals is seeking to hire a licensed LVN or RN to join their dynamic and collegiate team of professionals at their corporate offices in Burbank. This position will be remote during the pandemic.
GRIEVANCE & APPEALS COORDINATOR
The Grievance & Appeals Administrator will provide direction to claims staff regarding claims processing policies and procedures. Use independent judgment and discretion to review and resolve complex claim issues. Review, analyze, investigate, and make liability decisions and approvals for the release of benefit payment on utilization management files. Examine and process health insurance claims and service calls from physicians, hospitals and customers, as required. Adhere to claim and call policies and procedures while making accurate claim/call decisions. Research and resolve escalated and complex claim issues and maintain documentation associated with processing and handling of appeals to comply with regulatory standards and timeframes. Identify error trends and notify appropriate areas for correction, communicating/educating the necessary parties. Participates in data gathering and analysis of reports regarding appeal activity, as well as, prepares for appeal audits, monitors QI (Quality Improvement) activities of appeals team, and assists in the development of designated Claim staff, department flows and implementations.
KNOWLEDGE, SKILLS, ABILITIES:
REQUIREMENTS:
Equal Opportunity Employer considering qualified candidates in accordance with state and federal laws, including those with criminal histories, in a manner consistent with the City of Los Angeles’ Fair Chance Initiative for Hiring Ordinance.
Company Description
Details to be discussed during phone interview.