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SalaryThe Appeals and Grievance (A&G) Auditor ensures compliance with established internal control procedures by examining records, reports, operating practices, and documentation related to the Plan’s A&G processes and will have primary responsibility for monthly organization determinations and reconsiderations (ODAG) timeliness and documentation audits as well as oversight and support of the Plan’s internal proprietary A&G request system and processes.
Primary Duties and Responsibilities:
- Primary responsibility to perform audits of required % of A&G determinations, and letter output of those determinations.
- Apply policies and procedures to confirm that Appeals and Grievances meet the criteria for turnaround and/or accuracy requirements.
- Responsible for the administrative tracking of audits, and central storing of audit reports for A&G in SharePoint or other desired templates.
- Regularly performs quality check updates in policies, procedures, job aides, and other materials to ensure regulatory compliance and implementation.
- Review cases to assess whether the case was appropriately handled as a clinical or administrative matter and if correctly processed.
- Evaluate cases to determine if appropriate solicitation of records was conducted and if sufficient records were obtained.
- Prepare audit findings and recommendations.
- Identify and communicate error trends to improve overall quality of the Appeals and Grievance processes.
Experience Requirements:
- Prior managed care experience, including knowledge of CMS.
- Knowledge of ICD 10 and CPT/HCPCS codes
- Strong claims and workflow processes.
- Strong organizational skills
- Ability to perform independently and prioritize projects/assignments.
- Ability to meet deadlines.
- Excellent verbal and written communication skills
