Grievance & Appeals Coordinator II

We Help People Live their Lives to the Fullest Potential!

For more than 30 years, Beacon has changed the way people live with behavioral health conditions. Today, we are the undisputed leader in behavioral health management, serving 40 million people across all 50 states. At Beacon, we are committed to delivering a ‘world-class’ candidate experience from the moment you click ‘Apply’! Our goal is to help you reach your fullest potential, while utilizing your talents and expertise to help us deliver on our promise.

Do you have a passion for helping others? If so, we are looking for you!

Beacon is currently seeking a Quality Coordinator to join our team at our Rocky Hill, CT office. Initiates all correspondence related to administrative and medical necessity denials. Ensures that contractual timeframes are maintained. Manages, analyzes and reports on member and provider medical necessity appeal process and provider administrative appeal process. Provides overall project support for the staff of the Connecticut Behavioral Health Partnership (CT BHP) Quality Management (QM) Department. Project support includes the coordination of quality improvement initiatives and activities related to member and provider denial letters and appeals, higher level of care retrospective eligibility authorization requests, the support of the CT BHP quality infrastructure, and preparing and reporting on numerous aspects of quality

What does a typical day look like?

1.    Develops, implements and revises, as necessary, policies and procedures and workflows for appeals pursuant to revisions in health care accrediting standards, laws, regulations and client contract requirements.

2.     Coordinates the creation of all denial letters for both administrative and medical necessity denials. Logs and tracks when letters are mailed to members and providers. Complies with performance standards set by the contact relative to the issuing of the denial letters and notifies senior management when performance standards are not met.

3.    Coordinates the creation of the Certificate of Need (CON) letters. Logs and tracks when letters are mailed to providers. 

4.    Coordinates the overall process for administrative and medical necessity appeals – logs, tracks, and investigates appeal requests. Coordinates with local and National Medical Directors to review medical necessity appeal requests.  Compiles administrative appeal requests with rationales and conducts necessary research in preparation for the administrative appeal committee meetings.  Complies with performance standards set by the contact relative to the timeframes within which appeals need to be resolved and notifies management when the timeframes are not met.  Proactively identifies issues and/or trends requiring the attention of the Partnership’s senior management and facilitates their resolution.

5.    Trains new hires on a monthly basis on the process of offering appeals to members and providers. 

6.    Assists in preparing semi-annual and annual reports of the CT Engagement Center’s contract with the CT BHP.

7.    Prepares written assessment reports that describe results, operational strengths, opportunities for improvement and recommendations.

8.    Utilizes basic statistical concepts to evaluate the validity of findings and their applicability to quality and risk management processes and activities.

9.    Manages and reports on member and provider medical necessity appeals.

•         Maintenance of the appeals database

•         Documentation of appeals in database

•         Assists members and providers as needed in the appeal process

•         Interfaces with Clinical Department and Medical Affairs around scheduling Peer-to- Peer Advisor Reviews and documents the determinations in CareConnect

•         Interfaces with the Provider Relations Department on provider administrative appeals

•         Timely notification of determinations to members and providers.

10. Manages and reports on member and provider medical necessity appeals.

•         Maintenance of the appeals database

•         Documentation of appeals in database

•         Assists members and providers as needed in the appeal process

•         Interfaces with Clinical Department and Medical Affairs around scheduling Peer-to- Peer Advisor Reviews and documents the determinations in CareConnect

•         Interfaces with the Provider Relations Department on provider administrative appeals

•         Timely notification of determinations to members and providers

11.  Provides general administrative and basic project management support as well as development, management, and analysis to initiatives related to the improvement of the quality of the CT BHP services and operations.

12. Provides support to the quality management infrastructure in the collection of policies, procedures, and committee minutes.

What you Contribute?

Education: High School Diploma/GED, Bachelors preferred.

Experience:  Requires 3 years work experience either in customer service or in a behavioral health/human services/healthcare setting. Call center or customer services skills preferred. Knowledge of denials and appeals preferred.  

What Makes Us Different?

• Here, it’s not just a job – it’s an opportunity to change lives.
• Our employees are learners, innovators and original thinkers.
• Our mission and values guide the way we treat our members, providers and each other.

What We Have to Offer:

• Healthcare benefits available starting day 1!
• Health & wellbeing incentives, such as gym membership reimbursement
• 401K with company match to help reach your future financial goals
• Generous PTO, because we know life happens outside of work
• Tuition reimbursement so you can keep reaching your fullest potential

If Beacon sounds like the place for you, what are you waiting for? Apply with us today to get started!

Beacon Health Options is 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.

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