Grievance coordinator

City / State

Richmond, VA

Overview

Work Shift

First (Days) (United States of America)

Sentara Health is seeking to hire a qualified individual to join our team as a Appeals and Grievances Team Coordinator, Medicare

Position Status : Full-time, Day Shift

Position Location : This is an remote position for residents of Virginia or North Carolina

Standard Working Hours : 8 : 00AM to 5 : 00PM (ET).

Position Summary :

Provides leadership support and coaching to Appeals & Grievances staff. Conduct staff training on processes, systems, and regulatory requirements.

Performance coaching for Appeals Coordinators and provides feedback to help improve performance. Responsible for researching, analyzing, and making determinations on complex grievances and appeals and communicating final determinations.

As a Subject Matter Expert, they will aid in interpreting ambiguous coverage language. Assists with case summaries / responses to regulatory agencies, members, and any external parties representing members.

Monitors trends and analyzes grievance and appeals data for submission to appropriate parties. Provides input to the Legal Department on pleadings and other actions, as needed.

May audit or provide support to audits of grievances and appeals processes.

Assumes responsibility, accountability and leadership for the daily operations. First line supervisor in the Department responsible for quality and service.

Facilitates the work of assigned team members. Responsible for leading the Appeals efforts, providing oversight, training and guidance to the team.

Conducting in-depth investigation and documentation of member appeals and grievances in compliance with State law, applicable rules and regulations and provider and group agreements.

Works closely with the Plan's Medical Directors who are responsible for all decision regarding clinical appeals / grievances and the Appeals Manager who is responsible for non-clinical appeals and grievances.

Requirements :

3 years of experience with Healthcare Complaints / Appeals

5 years of experience with Managed Care

Must meet or exceed current appeals processing standards to include : intake, investigation and resolution accuracy.

Must possess excellent verbal and written skills, with the ability to speak to large groups.

Bachelor's Level Degree OR 5 or more years of Medicare appeals at a health plan.

Diversity and Inclusion at Sentara

Our vision is that everyone brings the strengths that come with diversity to work with them every day. When we are achieving our vision, we have team members that feel they belong and can be their authentic selves, and our workforce is reflective of the communities we serve.

We are realizing this vision through our Diversity and Inclusion strategy, which has three pillars : A diverse and talented workforce, an inclusive and supportive workplace, and outreach and engagement with our community.

We have made remarkable strides in these areas over the past several years and, as our world continues to evolve, we know our work is never done.

Our strategies focus on both structural inclusion , which looks at our organizational structures, processes, and practices;

as well as behavioral inclusion , which evaluates our mindsets, skillsets, and relationships. Together, these strategies are moving our organization forward in an environment that fosters a culture of mutual respect and belonging for all.

Please visit the link below to learn more about Sentara's commitment to diversity and inclusion :

https : / / www.sentara.com / aboutus / mission-vision-and-values / diversity.aspx

SentaraOverview

For more than a decade, Modern Healthcare magazine has ranked Sentara Health as one of the nation's top integrated healthcare systems.

That's because we are dedicated to growth, innovation, and patient safety at more than 300 sites of care in Virginia and northeastern North Carolina, including 12 acute care hospitals.

Sentara Benefits

As the third-largest employer in Virginia, Sentara Health was named by Forbes Magazine as one of America's best large employers.

We offer a variety of amenities to our employees, including, but not limited to :

Medical, Dental, and Vision Insurance

Paid Annual Leave, Sick Leave

Flexible Spending Accounts

Retirement funds with matching contribution

Supplemental insurance policies, including legal, Life Insurance and AD&D among others

Work Perks program including discounted movie and theme park tickets among other great deals

Opportunities for further advancement within our organization

Sentara employees strive to make our communities healthier places to live. We're setting the standard for medical excellence within avibrant, creative, and highly productive workplace.

For information about our employee benefits, please visit : Benefits - Sentara (sentaracareers.com)

Join our team!We are committed to quality healthcare, improving health every day, and provide the opportunity for training, development, and growth!

Please Note : The yearly Flu Vaccination is required for employment.

Note : Sentara Health offers employees comprehensive health care and retirement benefits designed with you and your family's well-beingin mind.

Ourbenefits packages are designed to change with you by meeting yourneeds now and anticipating what comes next. You have a variety of options for medical, dental and vision insurance, life insurance, disability, and voluntary benefits as well as Paid Time Off in the form of sick time, vacation time and paid parental leave.

Team Members have the opportunity to earn an annual flat amount Bonus payment if established system and employee eligibility criteria is met.

Job Summary

Assumes responsibility, accountability and leadership for the daily operations. First line supervisor in the Department responsible for quality and service.

Facilitates the work of assigned team members. Responsible for leading the Appeals efforts, providing oversight, training and guidance to the team.

Conducting in-depth investigation and documentation of member appeals and grievances in compliance with State law, applicable rules and regulations and provider and group agreements.

Works closely with the Plan's Medical Directors who are responsible for all decision regarding clinical appeals / grievances and the Appeals Manager who is responsible for non-clinical appeals and grievances.

Provide training and / or presentations to staff, external brokers and providers.

Knowledgeable of full range of products at Optima Health.

Must meet or exceed current appeals processing standards to include : intake, investigation and resolution accuracy.

Must possess excellent verbal and written skills, with the ability to speak to large groups.

Three (3) years of prior coding experience strongly preferred.

Qualifications :

BLD - Bachelor's Level Degree (Required)

Certified Professional Coder (CPC) - Certification - American Academy of Professional Coders (AAPC)

Healthcare Complaints / Appeals, Managed Care, Medicare Appeals

Skills

Active Learning, Active Listening, Communication, Coordination, Critical Thinking, Judgment and Decision Making, Leadership, Mathematics, Microsoft Access, Microsoft Excel, Microsoft Word, Monitoring, Reading Comprehension, Service Orientation, Social Perceptiveness, Speaking, Technology / Computer, Time Management, Troubleshooting, Writing

Sentara Healthcare prides itself on the diversity and inclusiveness of its close to an almost 30,000-member workforce. Diversity, inclusion, and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves.

Per Clinical Laboratory Improvement Amendments (CLIA), some clinical environments require proof of education; these regulations are posted at ecfr.

gov for further information. In an effort to expedite this verification requirement, we encourage you to upload your diploma or transcript at time of application.

In support of our mission "to improve health every day," this is a tobacco-free environment.

Last updated : 2024-03-24