Appeals & Grievances Coordinator

Who We Are Point
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Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point
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Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We’ve had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it’s at the core of who we are.

We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities. Learn more about who we are at Point
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Health .

Job Summary The Appeals and Grievance (A&G) Coordinator is responsible, per State and Federal regulations, for assisting with all operational aspects of the Appeals and Grievances assignment process for Point
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Health. Responsibilities include, but are not limited to: processing daily mail received by the A&G department, handling outgoing mail for the A&G department, distribution and classification of cases in compliance with applicable time frames and regulations, gathering information on behalf of the A&G Analyst with external vendors, coordinating the request for medical records, tracking effectuations, facilitating delivery of appeals and related information to key departments and appeals committee members;

analyzing and reporting data regarding department processes as requested from management; note trends in Appeals and Grievances and notify supervisors of their findings. The coordinator must possess a broad understanding of all Point
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Health lines of business and benefit structures as well as have an understanding of regulatory requirements and time frames. Essential functions will occur simultaneously; therefore, the employee must be able to appropriately handle each of these functions, prioritize them, and seek assistance when necessary. These essential functions need to be performed on a consistent and regular basis, using good judgment. The employee must be able to learn and apply Point
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Health’s policies and complex and frequently changing regulatory requirements consistently and the judgment to seek guidance as needed.

Job Description

Key Responsibilities /Duties – what you will be doing (top five):

Assign new verbal and written appeals and grievances to Appeals and Grievances Analyst.

Support A&G Analyst in timely completion of Appeals and Grievances.

Adheres to all regulatory, internal and compliance timeliness expectations.

Responsible for distribution of incoming mail as well as department manual mail processing.

Other duties and projects as assigned.

Qualifications – what you need to perform the job Certification and Licensure Education Required  (minimum):
Associate’s Degree or equivalent experience in health care, conflict resolution or related field

Preferred:

Experience Required (minimum): 1-2 years of member services representative/customer service experience in health care Preferred: 1-2 years’ Appeals and Grievance experience in assigning and handling appeals and grievances

Skill Requirements Excellent organizational skills required. Excellent interpersonal/communication skills are essential. Must have computer skills with experience in EXCEL, and WORD. Must have knowledge and demonstrated ability in the use of Windows applications and other comparable systems/applications.

Knowledge of basic…