Member Service Appeals and Grievances Coordinator
At Paramount, we offer insurance to both large and small groups and also cater to Medicare (Paramount Elite) subscribers in northwest Ohio and southeast Michigan. Our Medicaid product (Paramount Advantage) services those living in the state of Ohio. We maintain an accreditation by the NCQA – the National Committee for Quality Assurance – for our Ohio HMO, Elite and Advantage products. We’re also part of ProMedica, which is ranked the second most integrated health system in the U.S. and No. 1 in the Midwest. For more information about Paramount, please visit our website http://www.paramounthealthcare.com.
The Member Service Appeals and Grievance Coordinator (MSAGC) coordinate member administrative and/or medical appeals, including appeals, grievances, and regulatory requests on appeals/complaints/grievances. Provides support to quality improvement activities. Serves as an interdepartmental administrative liaison to ensure prompt resolution of member service issues and questions.
This position reports directly to the Manager of Member Services. No positions report to this position.
- Coordinates member appeals/grievances from initial communication through final determinations.
- Gathers and assesses appropriateness and completeness of all related medical/administrative information. Conducts relevant discussions with medical providers; obtains and assesses medical records and treatment plans; researches medical necessities by reviewing policies, protocols and regulatory guidelines.
- Conducts relevant discussions with Appeals and Grievances staff and Manager of Member Services.
- Ensures ongoing communications with the member(s) throughout the process of the Appeal/Grievance.
- Prepares summary information for presentation to State hearings, coordinates staff attendance at those hearings, and presents summary of cases to panel.
- Assists with grievance/complaint data review and input into database as well as the submissions to regulatory agencies.
- Addresses special member service and executive level inquiries and prepares ad-hoc reports as requested.
- Complete annual policy/procedure updates related to grievance and appeal processes based on regulatory updates and changes specific to product lines.
- Provides support, guidance, and assistance to the Member Services department staff relative to administrative procedures and general questions.
- Performs special projects to aid in the smooth functioning of the department and assists with telephone inquiries as required.
- Assists with departmental appeals/grievance training.
- Responsible to oversee the logging and reporting of Medicaid appeals and grievances and assuring that the grievance system is in accordance with the Ohio Administrative Code.
- Other duties as assigned.
- Minimum of two to four years clinical nursing experience.
- One year or more experience in utilization review in a health care delivery, managed care, or Medicaid organization required.
- Ability to maintain confidential information.
- Demonstrated computer skills, including experience with Microsoft Word required. Experience with Excel and Access preferred.
- Exceptional written, telephonic, and oral communication, problem-solving, interpersonal, and organizational skills required. Ability to coordinate and organize multiple priorities.
- Current Ohio nursing license required.
ProMedica is a mission-based, not-for-profit integrated healthcare organization headquartered in Toledo, Ohio. For more information, please visit www.promedica.org/about-promedica
Qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, religion, sex/gender (including pregnancy), sexual orientation, gender identity or gender expression, age, physical or mental disability, military or protected veteran status, citizenship, familial or marital status, genetics, or any other legally protected category. In compliance with the Americans with Disabilities Act Amendment Act (ADAAA), if you have a disability and would like to request an accommodation in order to apply for a job with ProMedica, please contact email@example.com
Equal Opportunity Employer/Drug-Free Workplace
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