REMOTE | Coordinator Appeals & Grievances

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At AmeriHealth Caritas, we are passionate about helping people get care, stay well, and build healthy communities. As one of the nation's leaders in healthcare solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services, and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we would like to hear from you.

Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

Discover more about us at www.amerihealthcaritas.com.

Reporting to the Supervisor, Appeals and Grievances, this position is responsible for the administrative tasks for coordination of member and/or provider appeals, the analysis of claims and appeals, and the review of medical management authorizations.

• Research and Investigate member and/or provider appeals and grievance requests, including review of UM/claim denial reasons, contract/regulatory rules, benefits, and documentation received on appeal/grievance
• Outreach call(s) made to members/participants, providers and /or member/participant representatives, to acknowledge receipt of appeal/grievance and discuss intent of appeal/grievance
• Explain the appeal/grievance process including helping members understand the outcome and implication of appeals decisions
• Prepares case file (original denial, all information received on appeal, medical records, etc.)
• Schedule participant/member for committee panel sends scheduling letter if needed
• Prepares, develops and presents written case summaries, if needed and process dictates, for all adverse determination for the purpose of conducting State Fair Hearings
• Prepare and send cases files to other teams as needed (e.g. legal, external appeals, state fair hearings, etc.)
• Communicates updates and status of outstanding member and provider complaints/issues to management
• Monitors to ensure that all problems with appeals/grievances presented by plan members/participants are resolved in accordance with established policies and procedures
• Update and/or generate authorization updates requests, for services that have been appealed
• Maintains accurate, timely, and complete record of appeals and grievances in the appeals system and documents, all correspondence with a member/participant, representative and/or a provider, related to an appeal or grievance issue
• Maintains quality and compliance standards as dictated by the state and federal entities
• Maintains contractual agreements with participating providers related to appeals and grievances
• Monitors caseload daily to ensure all cases are kept within compliance; follows up and escalates when compliance standards are at risk
• Actively seeks the involvement of the legal department or compliance department, as necessary, for clarification and supporting documentation by escalating issues to appeals and grievances management
• Obtain authorization for release of sensitive and confidential information
• Keeps current with rules, regulations, policies and procedures relating to Plan member benefits, member’s rights and responsibilities, and Complaints and Grievances
• Ensure case file is sent to appropriate committee for decision making or example, internal committee/panel, independent review organization, internal medical director - as process dictates
• Provide support presenting cases and facilitating committee meetings as needed
• Send appeal to an independent review organization portal, for those appeals that require an external match specialty review
• Obtain data from multiple systems/vendors to ensure all documentation needed for appeal is obtained, for e.g. PerformRX, LTSS and other systems/vendors as needed
• Collaboration with internal counterparts as needed to ensure proper handling of the appeal e.g. UM team, medical directors, claims, contact center, vendors as needed (e.g. PerformRX)
• Creates decision letter with detail description of the nature of appeal / grievance including rational for the decision and options for moving forward
• Initiate and follow up on effectuations (um authorization update/claim adjustment) for overturned appeals/grievances
• Keeps current with rules, regulations, policies and procedures relating to Plan member benefits, member’s rights and responsibilities, and Complaints and Grievances
• Ensure case file is sent to appropriate committee for decision making or example, internal committee/panel, independent review organization, internal medical director - as process dictates
• Provide support presenting cases and facilitating committee meetings as needed
• Send appeal to an independent review organization portal, for those appeals that require an external match specialty review
• Obtain data from multiple systems/vendors to ensure all documentation needed for appeal is obtained, for e.g. PerformRX, LTSS and other systems/vendors as needed
• Collaboration with internal counterparts as needed to ensure proper handling of the appeal e.g. UM team, medical directors, claims, contact center, vendors as needed (e.g. PerformRX)
• Creates decision letter with detail description of the nature of appeal / grievance including rational for the decision and options for moving forward
• Initiate and follow up on effectuations (um authorization update/claim adjustment) for overturned appeals/grievances

Education/ Experience:

• Required High School/GED.
• Required a minimum of two (2) years’ work experience in a Managed Care environment.
• 1 to 3 years' experience in grievance/appeals environment required.
• Proficiency with Windows and Microsoft Office applications, including Excel, Access, PowerPoint and Outlook
• Proven professional customer service telephone skills.
• Knowledge of the basic health care industry, managed care principles, claims, and medical terminology.
• Ability to work collaboratively or independently; deliver high-quality work; attention to detail and flexibility; excellent verbal and written communication skills communication skills.
  
• Core Hours: Monday-Friday, 8:30 am-5:00 pm, and Weekend rotations: extended hours 9 am -12 noon.

Diversity, Equity, and Inclusion

At AmeriHealth Caritas, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.

We keep our associates happy so they can focus on keeping our members healthy.

Our Comprehensive Benefits Package

Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.