Curana Health · 8 hours ago
Temporary Appeals and Grievances Specialist (68517)
United States
Full-time
Remote
Entry Level
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Responsibilities
Investigate and process member and provider appeals and grievances in a professional, timely manner, adhering to contractual time limits.
Have a clear understanding of the differences in medical necessity appeals and claim appeals
Works appeal and grievance cases which includes receiving, logging, tracking, monitoring, documenting, supporting documentation requests.
Responds to member and provider appeals with minimal direction
Prepares all appeals and grievances written documentation which include appeal and grievance outcome letters, appeal acknowledgement letters, and correspondences to next level of appeals
Documents all appeals and grievances in an accurate and timely manner per policy, related follow-up activities and final outcomes in designated systems while concurrently maintaining secure, comprehensive, and clearly defined files.
Generates reports with trend analysis and recommendations for quality improvement to Manager, as required
Communicates detailed risk management issues to the Manager within the specified timeframe
Read and comprehend appeal and grievance correspondences and reach out to appellant and or griever to obtain additional information as needed
Works closely with member advocates to gain resolution for grievances
Consults with internal departments such as Utilization Management, Claims, Provider Network and Legal, as well as company senior management to assure appeal and complaint decisions meet all guidelines and result in customer satisfaction when possible
Consults with Management and external vendors to resolve high profile, complex appeals and/or complaints.
Other duties as assigned
Qualification
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Required
Minimum of High school graduation or GED required.
Working knowledge of Medicare Advantage
Experience in Medicare Advantage health insurance including customer service
Exceptional interpersonal and problem-solving skills
Positive and approachable demeanor
Strong analytical and conflict resolutions skills as well as persuasion skills.
Proficient in MS Office applications (Word and Excel)
Ability to prioritize, work under pressure, while maintaining organization
Understanding of operational process flow analysis and process improvement methods
Experience working with firm deadlines with the ability to interpret and apply regulations.
Preferred
Strong working knowledge of medical claims adjudication, medical billing, terminology, insurance, or health services preferred
Familiarity with Medicare benefits preferred
Understanding of the long-term care and provider-sponsored plans industries
Ability and willingness to learn new software applications and adapt to change
Company
Curana Health
Curana Health are mission is to improve the health, happiness, and dignity of senior living residents.
1001-5000 employees
Funding
Current Stage
Late StageLeadership Team
Mark Price
CEO
Todd Tyler
CIO
Recent News
2023-09-11
Business Journals
2023-05-16
Company data provided by crunchbase
