Grievance and Appeals Specialist

Description

COMPANY OVERVIEW

Zing Health is a tech-enabled insurance company making Medicare Advantage the best it can be for those 65 and over. Zing Health has a community-based approach that recognizes the importance of the social determinants of health in keeping individuals and communities healthy. Zing Health aims to return the physician and the member to the center of the healthcare equation. Members receive individualized assistance to make their transition to Zing Health as easy as possible. Zing Health offers members the ability to personalize their plans, access to facilities designed to help them better meet their healthcare needs, and a dedicated care team. For more information on Zing Health, visit www.myzinghealth.com.

SUMMARY DESCRIPTION

The Grievance and Appeals Specialist position is responsible for reviewing and resolving members' and/or providers' complaints and communicating resolution to members or authorized representatives and/or providers in accordance with the standards and requirements established by the Centers for Medicare and Medicaid Services (CMS).

The Grievance and Appeals Specialist has frequent external contact with members and health care providers and interacts with and plays a key role in collaborating with internal contacts in Member Engagement, Provider Services, Pharmacy, Utilization Management, and other resources to identify factors necessary for the optimal resolution of complaints.

ESSENTIAL FUNCTIONS

• Be able to process both appeals and grievances.
• Have a strong Medicare Appeals processing background.
• Logging, tracking, and ensuring completion of all appeals, direct member reimbursements, and grievance cases in compliance with CMS standards.
• Manage tracking database to ensure the integrity of data and that all assigned cases are captured and maintained appropriately.
• Prepare documentation and transmit appeals of clinical denials to the appropriate professional for review and tracking review completion to ensure final closure of the associated case.
• Participate in all aspects of the direct member reimbursement, grievance & appeal process, specifically intake, triage, coordination, and documentation.
• Research, investigate, and resolve administrative aspects of appeals and/or grievances from Zing members and related outside agencies utilizing systems, clinical assessment skills, knowledge, and approved “Decision Support Tools” in the decision-making process regarding health care services and care provided to members.
• Assures the accuracy, timeliness, and appropriateness of all grievances and appeals according to state and federal, and Zing guidelines.
• Collaborate with internal departments as necessary (Customer Service, Provider Services, Quality, Claims, Utilization Management, and others to ensure the timely resolution of all grievances and appeals.
• Document the results of complaints and appeals and dispositions at all levels, including notification to providers and members.
• Prepare and determine the appropriate language for letters and prepare responses for all appeals and grievances.
• Assists with interdepartmental issues to help coordinate problem-solving in an efficient and timely manner.
• Assist the Manager of Grievance and Appeals in establishing and maintaining policies and procedures, compliance reporting, and training material.
• Manage workload volume, ensuring accuracy and compliance with scheduled deadlines.
• Perform other related duties as assigned.

Requirements

QUALIFICATIONS AND REQUIREMENTS

Required Qualifications

• High school diploma or GED with at least two years of college or equivalent experience
• Strong communication skills both oral and written
• Strong organizational skills, consistent attention to detail and independent problem-solving skills
• Minimum of two (2) years of experience in a Managed Care (Health Plan) environment performing appeals reviews/investigation or data analysis.
• Knowledgeable of various operational areas such as customer service, provider service, claims processing, utilization management, pharmacy and dental in a managed care setting.
• Ability to perform multiple tasks simultaneously, work under pressure and meet critical deadlines.
• Must possess a high degree of professionalism and business ethics.
• Knowledge of medical terminology, insurance terminology and benefit plan coverage and exclusions

Preferred Qualifications

• Familiarity with CMS claims denials and appeals processing, rules, regulations and accreditation standards and requirements.
• Advanced knowledge of computer systems, such as Microsoft Word, Excel, and Outlook.