Appeals & Grievance Coordinator I

Estimated Hiring Range:

Bonus Target:

Current CareOregon Employees: Please use the internal Workday site to submit an application for this job.

Essential Responsibilities

• Receive and validate requests for appeals and/or grievances.
• Review appeals and/or grievances to ensure compliance with state and federal requirements.
• Communicate with members and providers in accordance with state and federal requirements as needed to complete requests.
• Locate or request necessary information from internal and external sources to complete appeals and/or grievance reviews.
• Crosstrain on appeals, grievances, additional lines of business and other areas as needed.
• Maintain and track accurate and complete records and other documentation.
• Work with Quality Assurance clinicians, other CareOregon staff and delegated entities to ensure that appeals and/or grievance requests are managed in accordance with state and federal guidelines.
• Route appeals and/or grievance requests to the appropriate staff for additional review when needed.
• Create documents to share final resolution of appeal/grievance with members and/or providers.
• Prioritize and organize work to effectively meet strict deadlines as outlined by state and federal requirements; ask for assistance if uncertain of priorities.
• Responsible for consistently meeting high production and quality standards.
• Maintain confidentiality of all communications, records, and other data in accordance with HIPAA regulations, established quality management processes, and the highest professional standards.
• Collaborate with teams across the Clinical Operations department to ensure work and goals are met.
• Assist with gathering and assembling documentation and records needed for audits, external reviews, administrative hearings and internal committees.

Experience and/or Education

Required

• Minimum 1 year experience providing administrative support, customer service, clerical processing, and/or clerical production support

Preferred

• Experience with Appeals and Grievances, Claims or Utilization Management
• Experience working with Medicaid or Medicare
• Experience with insurance billing
• Experience in a medical, healthcare or insurance setting

Knowledge, Skills and Abilities Required

Knowledge

• Knowledge of medical and health insurance terminology preferred
• Knowledge of Medicaid health plan and Medicare benefits preferred
• Knowledge of applicable DMAP rules and regulations preferred
• Knowledge of managed care principles preferred

Skills and Abilities

• Ability to consistently meet high production standards
• Ability to consistently meet high quality standards
• Ability and willingness to cross-train as needed
• Ability to adhere to HIPAA regulations (e.g., maintain confidentiality of protected health information)
• Computer skills including ability to use Microsoft Office applications and internet search functions
• Ability to proofread work and ensure accuracy
• Ability to work in fast-paced environment with tight deadlines and high-quality standards
• Ability to independently prioritize work
• Growing ability to use critical thinking and problem-solving skills
• Excellent spoken and written communication skills, including correct spelling and grammar
• Good customer service skills
• Ability to work with internal and external people to effectively resolve cases
• Growing ability to respond to sensitive or complex issues with tact and diplomacy
• Good interpersonal skills and ability to work cohesively within a team environment
• Ability to work effectively with diverse individuals and groups
• Ability to learn, focus, understand, and evaluate information and determine appropriate actions
• Ability to accept direction and feedback, as well as tolerate and manage stress
• Ability to see, read, and perform repetitive finger and wrist movement for at least 6 hours/day
• Ability to hear and speak clearly for at least 3-6 hours/day

Working Conditions

Work Environment(s): ☒ Indoor/Office ☐ Community ☐ Facilities/Security ☐ Outdoor Exposure

Member/Patient Facing: ☐ No ☒ Telephonic ☐ In Person

Hazards: May include, but not limited to, physical and ergonomic hazards.

Equipment: General office equipment

Travel: May include occasional required or optional travel outside of the workplace; the employee’s personal vehicle, local transit or other means of transportation may be used.

Work Location: Work from home

We offer a strong Total Rewards Program. This includes competitive pay, bonus opportunity, and a comprehensive benefits package. Eligibility for bonuses and benefits is dependent on factors such as the position type and the number of scheduled weekly hours. Benefits-eligible employees qualify for benefits beginning on the first of the month on or after their start date. CareOregon offers medical, dental, vision, life, AD&D, and disability insurance, as well as health savings account, flexible spending account(s), lifestyle spending account, employee assistance program, wellness program, discounts, and multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings, etc.). We also offer a strong retirement plan with employer contributions. Benefits-eligible employees accrue PTO and Paid State Sick Time based on hours worked/scheduled hours and the primary work state. Employees may also receive paid holidays, volunteer time, jury duty, bereavement leave, and more, depending on eligibility. Non-benefits eligible employees can enjoy 401(k) contributions, Paid State Sick Time, wellness and employee assistance program benefits, and other perks. Please contact your recruiter for more information.

We are an equal opportunity employer

CareOregon is an equal opportunity employer.  The organization selects the best individual for the job based upon job related qualifications, regardless of race, color, religion, sexual orientation, national origin, gender, gender identity, gender expression, genetic information, age, veteran status, ancestry, marital status or disability. The organization will make a reasonable accommodation to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodation will impose an undue hardship on the operation of our organization.