Appeals And Grievances Coordinator

Pacificsource Boise , ID 83701

Posted 3 weeks ago

Looking for a way to make an impact and help people?

Join PacificSource and help our members access quality, affordable care!

PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.

Diversity and Inclusion: PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.

Position Overview:Coordinate the internal appeals and grievances process by supporting entry of requests in timely manner to internal decision makers. Provide supporting compliance interpretation. Conduct in-depth research of regulatory, legal, contractual, and root cause of case specifics. Support member and provider experience.

Essential Responsibilities:

  • Oversee and coordinate all Appeal and Grievance activities ensuring response deadlines are met in accordance with applicable best practice, state and federal guidelines.

  • Draft and provide acknowledgements by applicable method, to inquiries, grievances and appeals as required by regulations, PacificSource policy and department process standards.

  • Accurately interpret benefit language from Member and Provider contract language as well as State and Federal Regulation materials.

  • Prepare and provide response and resolution by applicable method to inquiries, grievances and appeals as required by regulations, PacificSource policy and department process standards.

  • Coordinate and execute external review and hearing processes provided to members under applicable State and or Federal regulations. Perform thorough investigations utilizing critical thinking, and root cause evaluation methods to make informed and justified decisions on behalf of PacificSource.

Supporting Responsibilities:

  • Meet department and company performance and attendance expectations.

  • Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.

  • Perform other duties as assigned.

Work Experience:

  • Minimum of two years customer service, claims processing or health insurance industry experience required.
  • 1+ year of technical writing and conflict resolution experience preferred.

Education, Certificates, Licenses: High School Diploma required; Bachelor's degree or equivalent experience preferred.

Knowledge:

  • Requires strong research, analytical and data entry skills.

  • Experience using Facets, Onbase, and other software packages used by PacificSource is strongly preferred.

  • Must have basic math skills, the ability to work under strict deadlines, and excellent organizational skills.

Competencies

  • Adaptability

  • Building Customer Loyalty

  • Building Strategic Work Relationships

  • Building Trust

  • Continuous Improvement

  • Work Standards

  • Contributing to Team Success

  • Planning and Organizing

Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5% of the time.

Our Values

  • We are committed to doing the right thing.

  • We are one team working toward a common goal.

  • We are each responsible for customer service.

  • We practice open communication at all levels of the company to foster individual, team and company growth.

  • We actively participate in efforts to improve our many communities-internally and externally.

  • We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.

  • We encourage creativity, innovation, and the pursuit of excellence.

Physical Requirements:Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.

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