A rewarding career that fits your life. Those who have joined the Banner mission come from all walks of life, united by the common goal: Make health care easier, so life can be better. If changing health care for the better sounds like something you want to be part of, apply today.
The Senior Grievance and Appeals Coordinator is responsible for providing assistance to health plan members and providers over the phone. This customer service role supports providers with complex claim dispute issues regarding Medicare and assisting members in filing their grievances, educating them on their benefits and resolving any barriers in their access to care.
As a seasoned customer service expert, you will provide resolution and options to callers that want an immediate response. In addition, we also help members file appeals for services they believe the health plan should pay for. We are a member centric department and assist all callers with empathy and resolution geared towards success.
Your pay and benefits are important components of your journey at Banner Health. Banner Health offers a variety of benefits to help you and your family. We provide health and financial security options so you can focus on being the best at what you do and enjoying your life.
Banner Health Network (BHN) 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 BHN, 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 The primary purpose of this position is to support the Grievance & Appeals Department by supporting the development of the team and by assisting in the preparation of the Health Plan in all State Hearings. This position is the standard by which each employee is to handle member and provider grievances, appeals and claim disputes. This position supports the development, implementation, maintenance and continuous improvement of the Grievance & Appeals department, programs and projects and assists the Grievance & Appeals Manager with day-to-day operations, ensuring production and quality standards according to contractual requirements.
CORE FUNCTIONS 1. Maintains State Fair Hearing Logs with appropriate information required by HP policy, AHCCCS, HCG and CMS regulations.
2. Reviews all State Fair Hearing requests by members and providers, pulls case files, meets with Grievance & Appeals Manager for further review and action which may include collaboration with others to avoid/reduce grievances, appeals and/or claim disputes. May attend State Fair Hearings.
3. Coordinates and assists the Grievance & Appeals Manager in preparing for higher level of appeals (i.e. Independent Review Entity reviews, hearings, etc.) including telephonic requests.
4. Assists with project management of departmental improvements. Coordinates with other departments on Grievance & Appeals projects/workgroups.
5. Assists the Marketing Department with the production of all member letters and notices. Participates actively in meetings, workgroups and committees relevant to the Grievance & Appeals process. May produces, prepare, quality check or deliver all reporting requirements in the absence of the Grievance & Appeals Manager.
6. Produces and analyzes weekly and monthly data to determine trends and provides recommendations for intervention. Assists with internal, external and self-audits of department and annual data validation.
7. Produces Monthly Operational Dashboard. Produces, analyzes and reports monthly data to ensure regulatory compliance. Updates Grievance & Appeals data in conjunction with the Marketing department on all HP websites.
8. Monitors and resolves member and provider expedited appeals and grievances received after hours and/or holidays when assigned to rotational on-call duty. Coordinates appropriate action by supporting clinical staff for processing of member and provider expedited appeals and/or grievances.
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.
Performs all functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards. Provides all customers of Banner Health with an excellent service experience by consistently demonstrating our core and leader behaviors each and every day.
Knowledge, skills and abilities as normally obtained through the completion of an Associate's Degree in Healthcare related field or Business or a relevant work experience in a health care related field showing increasing responsibilities to include project management. Three to four years of grievance and appeal work in a health care environment. Maintains knowledge of AHCCCS, HCG, and CMS regulations by participating in training, teleconferences and in-services.
Strong knowledge of administrative hearing processes for escalated grievances, appeals and claim disputes; Knowledge of Marketing Guidelines for AHCCCS, HCG and CMS. Knowledge of Health Plan policies, health care quality improvement initiatives and best practices, and program planning and project management best practices.
Skill in building and maintaining interpersonal relationships, and preparing and presenting detailed information to ensure understanding for a wide audience base. Ability to plan/direct projects, grasp new knowledge and concepts quickly and apply them, and assign workflow and tasks to other employees as needed for training purposes. Ability to organize, follow through and report results of interventions, conduct Grievance & Appeals related meetings, workgroups and committees, and to work cross functionally across the organization. Ability to support Grievance & Appeals Manager's work with attorneys, representatives and delegated persons regarding cases at the administrative hearing level; Ability to train new Grievance & Appeals coordinators, capable of mentoring trainees through a "buddy system". Skill in developing and managing teams; demonstrated critical thinking in resolving issues and conflicts.
Additional related education and/or experience preferred.
What might draw you to Banner Health? A great health care career, of course—and a great place to live, no matter what stage of life you’re in. With facilities across the West, there is a health care career for everyone, from big city living in the Phoenix area to friendly small towns in the mountains and plains. As one of the largest nonprofit health systems in the country, Banner Health offers both the stability that comes with success and the possibility of exploring new areas of the country. If you’re looking to be a key contributor to a forward-looking organization, you’ll experience a wide variety of professional advantages:
Our expansive system offers you an unmatched variety of clinical settings – from large urban trauma center to small rural hospital, ambulatory to home health.
Our commitment to healthcare innovation means you always have the latest technologies at your fingertips to help you provide the finest care possible.
The size, success and growth of our system provide you with the stability and options to pursue your desired career path.
Competitive compensation and comprehensive benefits offer you options to complement your unique needs.