Appeals and Grievance Specialist Lead
CHRISTUS System Office
CHRISTUS Corp Health Plan 919 and 909 Buildings
919 Hidden Ridge
Irving, TX 75038
USView Other Locations
Share This Job On
Apply Now Appeals and Grievance Specialist Lead Job in Irving
Responsible for reviewing and resolving critical and urgent inquiries including complaints received directly from members, providers, authorized representatives, Government Agencies, Regulatory and the Better Business Bureau. This position will specifically be responsible for handling issues dealing with complicated and/or technical nature. Prepare, analyze, and process expedited provider and member complaints, appeals, and claim disputes for all lines of business within timelines set by regulators. Ensure customer satisfaction and help establish best practices.
- Handle complex escalated issues and concerns for all lines of business.
- Interface with other departments or members and providers through written and verbal communications to handle complex and urgent customer situations; research complex member and provider complaints.
- Interface with Government Agencies, Regulatory and Better Business Bureau personnel.
- Based on the nature of the member or provider complaint, identifies the correct classification of the complaint and the associated member and provider rights and processing paths.
- Analyzes data collected and coordinates with member's treating providers and pertinent departments to resolve member's complaints.
- Coordinates with pertinent departments to effectuate resolution resulting from grievance and appeals resolution decisions made at the plan level or by independent review entities.
- Arranges for timely effectuation of resolution decided upon.
- Prepares and mails resolution decision letters that meet regulatory requirements for content and timeliness.
- Analyzes grievance and appeals data for the explicit purpose of identifying and communicating trended root causes of member and provider dissatisfaction.
- Recommends process improvements to pertinent departments within the CHRISTU Health Plan organization in order to achieve member and provider satisfaction and/or operational effectiveness and efficiencies.
- Ability to integrate and analyze information from several sources and problem solve towards a resolution within tight timelines.
- Respond and interact with compliance department for written responses.
- Determines additional levels of appeals that member is entitled to and processes them in accordance with applicable regulatory standards and requirements for timeliness.
- Collects, analyzes and interprets data collected on a weekly basis and communicates results in person or in writing to pertinent departments or committees.
- Tracks and trends grievances and appeals processed and communicate trends and implications to the Grievance and Appeals Manager, who in turn, integrates trends into a cohesive whole.
- Conducts individual or group training under the direction of the Grievance and Appeals Manager.
- Perform other duties as requested by management.
- Follow the CHRISTUS Health guidelines related to Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI).
- Attend weekly and monthly team and department meetings as appropriate.
- Ability to sit for long periods of time.
- Ability to organize and prioritize work to meet deadlines.
- Ability to work occasional long or irregular hours.
- Ability to work flexible work schedule including evenings and weekends.
- Associate Degree Preferred.
- Ability to communicate orally and in writing in a clear and straightforward manner
- Ability to prioritize and organize effectively
- Ability to use critical thinking in complex situations
- Ability to mentor and coach team members
- Knowledge of government and regulatory procedures
- Ability to work well with diverse groups of individuals.
- Utilizes effective communication and conflict management skills.
- Minimum of three years customer service experience.
- Minimum two years of experience processing grievances and appeals within a managed care setting.