Follow Grievances and Appeals processes and systems to ensure data quality to support quality, production and financial goals Investigate and thoroughly document findings on all grievances and appeals Prepare Appeal case recommendations for initial review process Coordinate appropriate reviewer assignment for Appeals and Grievance cases Responsible to move Appeals and Grievances through each review level to ensure timely completion Drive operational excellence into all processes and departmental interactions based on CMS and UST requirements Bring to management’s attention any system or process issues determined during the investigation of the appeal or grievance Coordinate effectively with the Information technology department on upgrades/fixes/changes Participate in the departmental audit/oversight program that focuses on continuous quality improvement Participate in compliance committees to help continuously improve initial decision making 

Requirements:

Bachelor’s degree or relevant combination of education and experience may be considered in lieu of degree Certification or progress toward certification is highly preferred and encouraged Experience in a grievance and appeals environment, including experience with the grievance and appeals regulations per CMS Experience in medical benefits and health care industry regulations and processes; experience in claims, authorizations, and Medicare Advantage plans Experience working in or with Medicare Advantage plans, or Independent Review Entities Experience with CMS regulations regarding Medicare Advantage, and Medicare Advantage plans appeals and grievance processes Knowledge in claims, authorizations, and Medicare Advantage plans Proven problem-solving skills and ability to translate knowledge to corporate departments Strong communication skills are required to understand, interpret, and communicate ideas Strong analytical, organizational, planning, and problem-solving skills Ability to effectively interface with employees at all levels Ability to define problems, collect data, establish facts, and draw valid conclusions Demonstrated track record of generating results and having an impact on organizations Strong focus and drive to serve the customer Ability to work in a high paced environment Ability to consistently meet deadlines