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Directs and coordinates day-to-day plan functions, including Reporting, Claims Administration, Encounter Data Quality, Grievance and Appeals, Information Technology and Systems, Enrollee Services, Provider Services, and Business Continuity Planning and Emergency Coordination.
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All cases are data entered into the grievance and appeals electronic system (GATS) for reporting and tracking purposes. Assist with imaging and attaching grievance and appeals documents to the electronic tracking system (GATS.
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Health plan core systems i.e. claims, membership, grievance and appeals. Business Intelligence skills i.e. analytics/reporting with POWER BI or other similar BI tool. Health plan core systems i.e. claims, membership, grievance and appeals.
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Grievance and Appeals. Knowledge of full range of product requirements from regulatory, operations, clinical, reporting and compliance. Develop and maintain in-depth knowledge of the company’s regulatory environment, and assist in transforming regulatory procedures into polices, plan changes, reporting or other operational outcomes for plan start up.
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Maintain the monthly reporting responsibilities, Appeals and Grievance reporting to Department Director, ongoing referrals and authorizations for members in complex care management.
$47,840 - $68,474 a yearFull-timeExpandApply NowActive JobUpdated 1 days ago - UpvoteDownvoteShare Job
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Knowledge, Skills, and AbilitiesDetail oriented, excellent verbal and written communication and organizational skillsUnder general supervision of the Grievance and Appeals Manager performs a variety of complex, responsible and confidential duties requiring a thorough knowledge of organizational procedures and precedents perform routine clerical, administrative duties in support of the Grievance and Appeal Department.
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Must compile the original denial and reconsideration referrals into a well prepared packet and forward to the appropriate health plan's Appeals and Grievance Departments. Responsible for processing of Health Net Exchange Grace Period reporting and written notifications.
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Works closely with Office of General Counsel Services on the clinical issues that arise in the grievance and appeals process and participates in Administrative Hearings. As the Deputy Medical Director reporting to the Division of Fee-for-Service Management (DFSM) Medical Director, this position is responsible for decisions related to medical care and day-to-day availability for consultation regarding services provided to the AHCCCS Fee-For-Service (FFS) Acute Care, ALTCS, and special populations, as well as oversight of the care rendered to the AHCCCS population by various contractors and programs.
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Job Summary The Grievance Resolution Specialist coordinates the Grievance and Appeal resolution process, responds to verbal and written Grievances and Appeals from members and/or providers relating to member eligibility and benefits, contract administration, claims processing, utilization management decisions, and pharmacy and vision decisions.
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Tracking and documenting of all identified errors by UM staff members and reporting errors to management bi-weekly to ensure training to staff in needed areas. Demonstrate a complete understanding of established UM/ HPN, Health Plan and regulatory policies and procedures in regard to prior authorizations, appeals grievances, and reconsiderations.
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Responsible for grievance and appeals coordination and resolution for all Samaritan Health Plan (IHN, SAHP, Commercial, Choice) members who engage with the grievance process. Responsible for the documentation, monitoring and regulatory reporting obligations.
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Maintain an understanding of utilization management/grievance and appeals program objectives and design, implementation, management, monitoring, and reporting. We are seeking a dynamic Clinical Reviewer will be responsible for performing clinical and administrative reviews within the Grievance and Appeals department, ensuring accurate administration of benefits, execution of clinical policy, timely access to appropriate levels of care and provision of payment for services that have already been rendered.
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Seek to resolve differences in accordance with the scriptural patterns summarized in the Staff Manual policy on Fair Treatment as well as the Grievance and Appeals Procedure. Complete clerical tasks assigned by the Chief Information Officer or the AVClassroom Specialist, including but not limited to reporting on inventory, updating schedules, etc.
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Ensure that the Grievance and Appeals department processes all appeals and grievances in accordance with referred time frames and other contractual legal requirementsMonitor appeals and grievances and provide senior management with monthly reporting on trendsEnsure that all members and provider grievances are processed and investigated according to contract requirementsReview and enhance quality of care process in order to streamline tracking process for state reports.
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How you will make an impact: This position will be reviewing, creating appropriate reports, and monitoring in relation to funded services, DCF Trackers/inquiries, incident reporting, mortality reviews, grievance/appeals and utilizing this information to initiate regional improvements.
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grievance appeals reporting jobs
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