Appeals & Grievance Coordinator II
Company: Beacon Health Options
Location: Grand Rapids
Posted on: May 23, 2020
Beacon Health OptionsJob Category: Clinical -
Grievance/AppealsReq #: APPEA02270Schedule: Full TimeLocation: MI -
Grand RapidsAbout the Position:
Beacon Health Options is currently seeking a dynamic Appeals &
Grievances Coordinator II to join our team in Grand Rapids, MI. The
Appeals & Grievances Coordinator II responsible for the processing,
tracking and follow up of all medical necessity denials and appeals
and Fair Hearings resolution for commercial products and government
programs. This individual is required to have the ability to
provide excellent customer service to providers and members and the
ability to perform in potentially stressful situations, such as
state, federal, NCQA, URAC or other regulatory / accrediting agency
- Maintains systems and processes for the timely and accurate
resolution of all medical necessity denials, appeals, and fair
hearings including the tracking of information, system
documentation, sending adverse determination letters to providers
and members within established client service level agreements,
performance guarantees and regulatory requirements.
- Review Peer Advisor and/or Clinician determinations to ensure
that regulatory, accreditation, and client requirements are
- Compose decision letters under the direction of utilization
management, clinical operations, and issue final determination
response to member and provider.
- Responsible for verbal communications of denial, appeal and
fair hearing outcomes to member and providers.
- Manages case assignments including appeal review scheduling,
point of contact for appeal requestor to respond to questions
concerning the appeal process, quality assurance process for appeal
resolution letter, and liaison for functional inter-departmental
- Support and manage appeal inventory queues for timeliness,
appeal documentation, and case management according to client
performance guarantees and departmental service level
- Provide assistance and guidance to Appeals Coordinator staff as
needed; identifying training and development needs as required with
recommended action plans to Manager.
- Lead and support the research, analysis and resolution of
complex denial, appeals and fair hearings, identifying trends to
improve efficiencies and quality of service.
- Assists in quality management as required including client and
corporate audits, accreditation, quality improvement initiatives,
and performance standard teams.
- Resolve appeal call contact follow ups and escalations triage
from Service Operations or management.
- Responsible for processing fax and email receipts of appeal
requests including building appeal cases, triage to clinical
operations and/or National scheduling, and detail case
- Attend and Represent the company in Fair Hearing
- Other duties as assigned.
- Education:A.A.S. degree required, B.S. degree preferred
- Relevant Work Experience: 2 years of experience in healthcare,
behavioral health, or a related field required
- Travel: up to 10% local travel required
- Licensure: unrestricted driver's license required
Beacon Health Optionsis proud to be an Equal Opportunity and
Affirmative Action Employer as well as a Drug Free and Tobacco Free
Work Environment. EOE/AA/M/F/Veterans/Disabled
At Beacon Health Options, our candidate's data privacy is a top
priority. Our recruiting team conducts all communications using
official company email (@BeaconHealthOptions.com). Only candidates
who have applied for an open position through our Careers page
(careers.beaconhealthoptions.com) will be engaged in our interview
process. Beacon conducts all interviews in person or over the
phone. At no time during the recruiting process will any Beacon
recruiter request any financial or personally identifiable
information from you.
Keywords: Beacon Health Options, Grand Rapids , Appeals & Grievance Coordinator II, Other , Grand Rapids, Michigan
Didn't find what you're looking for? Search again!