Primary City/State:
Phoenix, ArizonaDepartment Name:
Grievances \& AppealsWork Shift:
DayJob Category:
General Operations
Banner Plans \& Networks (BPN) is a nationally recognized healthcare leader that integrates Medicare and private health plans. Our main goal is to reduce healthcare costs while keeping our members in optimal health. BPN is known for its innovative, collaborative, and team\-oriented approach to healthcare. We offer diverse career opportunities, from entry\-level to leadership positions, and extend our innovation to employment settings by including remote and hybrid opportunities.
Appeals and Grievances Management
- Review, research, investigate, and resolve both verbal and written appeals and grievances from members and providers.
- Ensure all cases are handled within required timeframes and regulatory guidelines.
- Prioritize and multitask across multiple cases simultaneously.
- Handle inbound and outbound calls related to appeals and grievances.
- Provide clear, empathetic, and professional communication to members and providers.
- Document all interactions and case progress accurately.
- Maintain detailed and accurate records of case handling and resolutions.
- Ensure all written communications are clear, grammatically correct, and compliant with internal standards.
This role and training are remote. Arizona residency is required for this role for compliance. Shifts are Monday \- Friday from 8:30 a.m.\-5:00 p.m.
If this role sounds like the one for you, apply today.
Banner Plans \& Networks (BPN) is an accountable care organization that joins Arizona's largest health care provider, Banner Health, and an extensive network of primary care and specialty physicians to provide the most comprehensive healthcare solutions for Maricopa County and parts of Pinal County. Through BPN, known nationally as an innovative leader in new health care models, insurance plans and physicians are coming together to work collaboratively to keep members in optimal health, while reducing costs.
POSITION SUMMARY
This position handles member and provider grievances, standard appeals and claim disputes. This position will act as a key advocate and contact for HP members with general health care and accessibility concerns and inquiries on the various levels of the grievance and appeals process.
CORE FUNCTIONS
1\. Determines which claim disputes meet acceptable claim dispute criteria, specifically screening for Untimely claims and Resubmissions; maintains a log, categorizes and tracks all received documents, notices, returned receipts; decides and responds to those appeals and claim disputes not meeting criteria with appropriate correspondence and routing. Assists in resolving member questions and concerns regarding the health care system in an effort to prevent the need for members to file formal grievances or appeals.
2\. Enters all accepted appeals and claim disputes and its corresponding information into the CRM; creates and maintains case files, including appropriate review sheets for Medical Review and/or Claim Review according to policy, AHCCCS, HCG, and CMS regulations; updates CRM for ongoing cases with responses from reviewers. Assesses individual cases and documents in various CRM programs for pertinent information for referral and/or transmission to co\-workers.
3\. Ensures all appeals and claim disputes are acknowledged, by official correspondence, within AHCCCS, HCG, and CMS contractual timelines; protects the confidentiality of member information and other information. Facilitates, communicates and accepts input regarding member and provider appeal information from appropriate individuals that would include employees, providers, Medical Director, Plan Administrator, RNs, Risk Management, attorneys, AHCCCS, HCG, CMS and others.
4\. Responds to all incoming phone calls, researches and resolves member and provider questions and concern regarding grievances, appeals and claim disputes. Opens, reviews, researches (if necessary), date stamps and routes or responds to all incoming mail. Responds in an expedient manner that is consistent with the mission and values of UAHN and in support of related regulations and policies and procedures to member, staff and physician grievances, appeals and claim disputes with minimal supervision.
5\. Creates and submits all resolution and extension correspondence, utilizing appropriate Arizona Revised Statues, Arizona Administrative Code, Code of Federal Regulations, and other supporting regulatory policies and statutes for all UAHP managed plans. Self\-audits daily to ensure compliance with regulatory requirements.
6\. Recognizes, facilitates and gathers relevant medical records, coding and claim documentation that is required for the reviewers to fully investigate grievances, appeals, and claim disputes. Responsible for trouble shooting, identifying, and resolving special handling requirements related to grievance and appeal issues.
7\. Reports at Grievance/Appeals meetings, as appropriate, all incoming, attended and scheduled State Fair Hearings.
8\. Works internally with other departments in order to facilitate timely responses and inquiries, and assists with workgroups as requested. Provides technical expertise to other departments regarding grievances, appeals and claim disputes.
9\. This position works under supervision, prioritizing data from multiple sources to provide quality care and support. Incumbents work in a fast\-paced, sometimes stressful environment with a strong focus on customer service. Interacts with staff at all levels throughout the organization.
MINIMUM QUALIFICATIONS
High school diploma/GED or equivalent working knowledge. Two years of work experience in health care related field or experience managing projects/initiatives, or an equivalent combination of education and experience.
Knowledge of AHCCCS, HCG and/or CMS regulations. Knowledge of MS Word, Excel and Microsoft Office Suite required. Knowledge of Medical terminology, claims processing guidelines, and CRM \& IDX. Knowledge of grievance, appeal and claim dispute processes.
Strong interpersonal, organizational and problem solving skills. Strong oral and written communication skills required. Ability to work independently ensuring all deadlines/timelines are met and to work with various levels of healthcare professionals. Ability to be flexible and work on a variety of projects simultaneously under tight time constraints. Strong analytical, critical\-thinking and time management skills. Strong organizational skills and ability to prioritize multiple tasks daily. Ability to quickly identify, summarize and present (verbally and orally) options to issues which may arise, and to consistently meet and exceed regulatory reporting requirements for all lines of business.
PREFERRED QUALIFICATIONS
Additional related education and/or experience preferred.
EEO Statement:
EEO/Disabled/Veterans
Our organization supports a drug\-free work environment.
Privacy Policy:
Privacy Policy