Job Description
Responsible for the initial assessment, review, and determination of the validity of an appeal and/or grievance type for all cases coming into the department.. Uses critical thinking and decision making to correctly identify and assign the appeal/grievance type to ensure compliance with the regulations outlined by the North Carolina Department of Insurance (NCDOI), the National Committee for Quality Assurance (NCQA), the Department of Labor (ERISA) and the Centers for Medicare and Medicaid Services (CMS). Responsible for determining the appropriate response based on the type of case from the initial research performed. . Communicate receipt of the case with internal and external stakeholders including but not limited to members, physicians, attorneys, etc. within the prescribed regulatory/accreditation timeframe to ensure compliance. Responsible for initiating the initial research on the appeal/grievance from the numerous systems to ensure all data is captured for entry into the appeals and grievances system... Participates in identification, problem solving, and improvements in product design, policies and processes affecting Member Rights and Appeals. The Resolution Coordinator is also the forefront of any incoming correspondence to the Appeals unit. This person is responsible for setting the pace of the workflow within the unit. Performs initial research and documentation of all incoming appeals and, grievances. Demonstrates the ability to research benefits, Plan policies, provider contracts, and determine the appropriate time frames applicable to an incoming request Determines the validity of all incoming appeals and makes critical decisions to keep and work as a valid appeal or send letter back to requestor indicating the appeal is non-valid and provide rationale for the non-valid decision. Provide member education regarding appropriate submission of inquiries. Provides mandated written responses to appellants of receipt of appeal, need for additional information and may provide interim responses giving notice of an extension of the appeals process to unforeseen delays, (i.e.) Acknowledgement letters and 3rd party authorizations forms, Appointment Of Representative and Waiver Of Liability forms. Researches all department requests, set up, and assign cases, as well as maintain files within the unit Identifies all misrouted inquiries and handles accordingly Provides direct feedback to Appeals Department management for identified problems Identifies additional tasks and works independently to ensure all up front functions run smoothly, which may include scanning and imaging as required, answer member/provider questions via incoming telephone calls in a professional quality driven manner Analyzes and coordinates all aspects of the appeals process to ensure compliance with our medical necessity criteria, Corporate Medical Policy, contract provisions, NC DOI, legislative and NCQA requirements Sorts, and distributes all incoming request via direct mail, right fax and Macess in a timely efficient manner throughout the day to ensure regulatory filing requirements are met Date stamp and initial all incoming correspondence via direct mail
Company Description
The Jacobson Group is the leading provider of insurance talent. For 50 years, we have been connecting insurance organizations with professionals from the board room to the back room on both a permanent and temporary basis. We offer a variety of solutions including executive search, professional recruiting, RPO, temporary staffing, subject matter experts, and onsite and work-at-home operations support. Regardless of the need or situation, Jacobson is the insurance talent solution.