The primary purpose of this position is to support the Grievance & Appeals Department by supporting the development of the team and by assisting in the preparation of the Health Plan in all State Hearings. This position is the standard by which each employee is to handle member and provider grievances, appeals and claim disputes. This position supports the development, implementation, maintenance and continuous improvement of the Grievance & Appeals department, programs and projects and assists the Grievance & Appeals Manager with day-to-day operations, ensuring production and quality standards according to contractual requirements.
Maintains State Fair Hearing Logs with appropriate information required by HP policy, AHCCCS, HCG and CMS regulations.
Reviews all State Fair Hearing requests by members and providers, pulls case files, meets with Grievance & Appeals Manager for further review and action which may include collaboration with others to avoid/reduce grievances, appeals and/or claim disputes. May attend State Fair Hearings.
Coordinates and assists the Grievance & Appeals Manager in preparing for higher level of appeals (i.e. Independent Review Entity reviews, hearings, etc.) including telephonic requests.
Assists with project management of departmental improvements. Coordinates with other departments on Grievance & Appeals projects/workgroups.
Assists the Marketing Department with the production of all member letters and notices. Participates actively in meetings, workgroups and committees relevant to the Grievance & Appeals process. May produces, prepare, quality check or deliver all reporting requirements in the absence of the Grievance & Appeals Manager.
Produces and analyzes weekly and monthly data to determine trends and provides recommendations for intervention. Assists with internal, external and self-audits of department and annual data validation.
Produces Monthly Operational Dashboard. Produces, analyzes and reports monthly data to ensure regulatory compliance. Updates Grievance & Appeals data in conjunction with the Marketing department on all HP websites.
Monitors and resolves member and provider expedited appeals and grievances received after hours and/or holidays when assigned to rotational on-call duty. Coordinates appropriate action by supporting clinical staff for processing of member and provider expedited appeals and/or grievances.
Knowledge, skills and abilities as normally obtained through the completion of an Associates Degree in Healthcare related field or Business or a relevant work experience in a health care related field showing increasing responsibilities to include project management. Three to four years of grievance and appeal work in a health care environment. Maintains knowledge of AHCCCS, HCG, and CMS regulations by participating in training, teleconferences and in-services.
Strong knowledge of administrative hearing processes for escalated grievances, appeals and claim disputes; Knowledge of Marketing Guidelines for AHCCCS, HCG and CMS. Knowledge of Health Plan policies, health care quality improvement initiatives and best practices, and program planning and project management best practices.
Skill in building and maintaining interpersonal relationships, and preparing and presenting detailed information to ensure understanding for a wide audience base. Ability to plan/direct projects, grasp new knowledge and concepts quickly and apply them, and assign workflow and tasks to other employees as needed for training purposes. Ability to organize, follow through and report results of interventions, conduct Grievance & Appeals related meetings, workgroups and committees, and to work cross functionally across the organization.Ability to support Grievance & Appeals Managers work with attorneys, representatives and delegated persons regarding cases at the administrative hearing level; Ability to train new Grievance & Appeals coordinators, capable of mentoring trainees through a buddy system. Skill in developing and managing teams; demonstrated critical thinking in resolving issues and conflicts.
Additional related education and/or experience preferred.
Internal Number: 251345
About Banner Health
You want to change the health care industry – one life at a time. You belong here. You’re excited to be part of the dramatic changes happening in the health care field. In fact, you thrive on change. But you also understand that excellent, compassionate patient care is the true measure of the success of these changes. You belong at Banner Health. Our award-winning, comprehensive health system includes 23 hospitals in seven western states, primary care health centers, research centers, labs, a network of physician practices and much more. Throughout our system, skilled, compassionate professionals use the latest technology to change the way care is provided. If you’re looking to be a key contributor to a forward-looking organization, you’ll experience a wide variety of professional advantages: •Our vision for changing the future of health care gives you the opportunity to leverage your abilities to achieve something historic. •Our expansive system offers you an unmatched variety of clinical settings – from large urban trauma center to small rural hospital, ambulatory to home health. Our system also includes hospitals specializing in cancer, heart health and pediatrics. •Our many loc...ations also translate into a broad selection of exciting and rewarding lifestyle options – from the big city to the wide-open spaces. •Our commitment to healthcare innovation means you always have the latest technologies at your fingertips to help you provide the finest care possible. •The size, success and growth of our system provide you with the stability and options to pursue your desired career path. •Our competitive compensation and comprehensive benefits offer you options to complement your unique needs.