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Robert Half Appeals & Grievance Coordinator in Mid-Wilshire, California

Description

A Medical IPA located in the Mid-Wilshire area is in need of Appeals & Grievance Coordinator. The Appeals & Grievance Coordinator will be responsible for the investigation, documentation and resolution of participant appeals in compliance with State/Federal law, rules, and guidelines. The Appeals & Grievance Coordinator will perform research and utilize extensive claims knowledge to respond to inquiries and interpret plan/policy provisions.

Duties Include:

· Work independently using discretion and independent judgment under the general supervision of the department manager and within broad parameters of policy established by management:

· Conduct research to advise management on medical claims issues and develop guidelines for use by the examiners or Participant Services Representatives when necessary.

· Research correspondence and appeals submitted by participants and providers.

· Manage documentation and correspondence for all appeals cases.

· Prepare and write appeals cases and present to the Benefit Committee.

· Coordinate reviews regarding the medical necessity of services with the Health Plan’s medical consultants. Write determination letters regarding the outcome of the reviews and send to the applicable participant/provider.

Requirements

Medical Claims

Medical Billing

Medical Terminology

Medical Appeals

Medical Grievances

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Questions? Call your local office at 1.888.490.3195. Robert Half will consider qualified applicants with criminal histories in a manner consistent with the requirements of the San Francisco Fair Chance Ordinance. All applicants applying for U.S. job openings must be legally authorized to work in the United States. Benefits are available to temporary professionals. Visit https://roberthalf.gobenefits.net/ for more information.

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