Appeals & Grievances Coordinator - Care 'N Care
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Position Responsibilities SWHR Appeals & Grievances Coordinator tracking of daily Appeals, Grievances, and Complaints to ensure that the health plan adheres to regulations and timeframes set forth by CMS. Interact with health plan members, various departments, and vendors (as needed) to research member appeals, grievances, and complaints. Processes information within CMS timeframes in response to inquiries, concerns and requests. Reconciles across systems to ensure that all member appeals, grievances, and complaints are logged and tracked. Escalates to management as needed to ensure CMS timeframes are met before the deadline. Ensures plan is represented in a professional manner and with a high level of attention to customer service and detail. Interface with CNC operational departments and FDRs as necessary with a focus on positive problem solving. Prepares letters, presentations, and spreadsheets as needed and create reports on a regular basis. Adheres to CMS regulations and changes, and create new processes as needed.
Qualifications
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High School Diploma or Equivalent (required) and
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Other coursework in Healthcare, Marketing, Communications, Public Relations or Business (preferred)
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3 years relevant experience Required
Position Responsibilities SWHR Appeals & Grievances Coordinator tracking of daily Appeals, Grievances, and Complaints to ensure that the health plan adheres to regulations and timeframes set forth by CMS. Interact with health plan members, various departments, and vendors (as needed) to research member appeals, grievances, and complaints. Processes information within CMS timeframes in response to inquiries, concerns and requests. Reconciles across systems to ensure that all member appeals, grievances, and complaints are logged and tracked. Escalates to management as needed to ensure CMS timeframes are met before the deadline. Ensures plan is represented in a professional manner and with a high level of attention to customer service and detail. Interface with CNC operational departments and FDRs as necessary with a focus on positive problem solving. Prepares letters, presentations, and spreadsheets as needed and create reports on a regular basis. Adheres to CMS regulations and changes, and create new processes as needed.
In addition to the required qualifications, a successful Appeals & Grievances Coordinator will:
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broad understanding of financial and accounting principles
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demonstrates a general knowledge of healthcare delivery systems
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strong Independent decision making and problem solving
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excellent interpersonal communication (oral and written)
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strong organizational skills and ability to adhere to timelines
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background in healthcare and/or health insurance industry
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ability to work well on a team
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extremely Proficient with Microsoft Office (Excel, Word, PowerPoint) and other applicable software applications
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strong attention to detail
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ability to work in various application and systems (Salesforce, Virtual Appeals Manager)
Why Southwestern Health Resources
As a Southwestern Health Resources you’ll enjoy: comprehensive benefits, including a 401(k) with match; paid time off; competitive health insurance choices; healthcare and dependent care spending account options; wellness programs to keep you and your family healthy; tuition reimbursement; a student loan repayment program; and more.
As a Southwestern Health Resources you’ll enjoy: comprehensive benefits, including a 401(k) with match; paid time off; competitive health insurance choices; healthcare and dependent care spending account options; wellness programs to keep you and your family healthy; tuition reimbursement; a student loan repayment program; and more.
Moving healthcare forward
At the heart of SWHR are people who help people. We care about those we serve and each other. To be the national leader in providing population-based healthcare, our more than 850 employees use their knowledge, data insights and clinical experience to deliver care to the right patient, at the right time and in the right setting. By connecting physicians to patients and clinical insights to better outcomes, SWHR lowers costs, optimizes value, and builds a better healthcare system for all.
At the heart of SWHR are people who help people. We care about those we serve and each other. To be the national leader in providing population-based healthcare, our more than 850 employees use their knowledge, data insights and clinical experience to deliver care to the right patient, at the right time and in the right setting. By connecting physicians to patients and clinical insights to better outcomes, SWHR lowers costs, optimizes value, and builds a better healthcare system for all.
We invite you to learn more about us at www.southwesternhealth.org.
Let’s move healthcare forward – together.
Highlights:
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Combining the strengths of UT Southwestern Medical Center, Texas Health Resources and more than 2,500 community physicians, we offer the largest provider network in North Texas. SWHR covers approximately 700,000 patient members across 16 counties in North Texas.
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SWHR is the parent organization of Care N’ Care Insurance Co., a leading regional Medicare Advantage health plan organization that serves approximately 17,000 patients in North Texas.
Additional perks of being a SWHR Appeals & Grievances Coordinator
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Gain a sense of accomplishment by contributing in a teamwork environment
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Positively impact patients’ quality of life
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Receive excellent mentorship, comprehensive training and dedicated clinical leadership resources
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Enjoy opportunities for growth
Explore Southwestern Health Resources Careers for more information and to search all career opportunities.
Our Recruitment team invites you to contact us with any questions at recruitment@texashealth.org.