Appeals and Grievance Coordinator

Express Employment Professionals - Grants Pass, OR

Full-time

Grants Pass, OR

Administrative and Support Services

About the position

The Appeals and Grievances Coordinator is responsible for processing and resolving appeals and grievances from Oregon Health Plan and Advantage Health Plan members and providers. This role involves investigating complex complaints and ensuring compliance with relevant regulations, making it essential for maintaining the integrity of the health plan's operations.

Responsibilities

• Investigate and resolve complex member and provider complaints related to enrollment, claims, and medical appeals.
• Prepare complete case files for the medical director to facilitate the processing of appeals and grievances.
• Forward appeals to CMS Independent Review Entity or DMAP for further review and collaborate with these entities during the process.
• Process appeals and grievances across all lines of business, including case file development.
• Track and monitor trends in appeals and grievances and respond to incidents in the CMS/HPMS Complaint Tracking Module.
• Assist with DMAP administrative hearings and attend CMS Part C and D monthly user calls.
• Analyze and report quarterly to DMAP and monthly to CMS Regional Office.
• Support audits conducted by CMS and DMAP and assist with provider/member education as needed.
• Maintain knowledge of Medicare, Medicare Part D, and Oregon Health Plan regulations.
• Participate in departmental projects and travel as necessary.

Requirements

• Bachelor's degree (BA) from a four-year college or university; or one to two years of related experience and/or training; or an equivalent combination of education and experience.
• Valid insurable Driver's License.
• Certified Professional Coder (CPC) certification is strongly preferred.