Experience Inc. Jobs

Career Opportunities: Appeals & Grievance Coordinator I (24454) Requisition ID 24454 - Posted 07/25/2024 - CareOregon - Full Time - Permanent - Portland - Multi Location (9) Job Description Print Preview Candidates hired for remote positions must reside in Oregon, Washington, Utah, Idaho, Arizona, Nevada, Texas, Montana, or Wisconsin. Job Title Appeals & Grievance Coordinator I Department Clinical Operations Exemption Status Non-Exempt Requisition # 24454 Direct Reports N/A Manager Title Quality Assurance Supervisor Pay & Benefits Estimated hiring range $51,800 - $63,320/year, 5% bonus target, full benefits. www.careoregon.org/about-us/careers/benefits Posting Notes This role is fully remote but must reside in one of the listed 9 states. Job Summary The Appeals & Grievance Coordinator I position is responsible for coordinating appeals and/or grievances at the entry level. This includes tracking, documentation, collection and file maintenance, all in strict compliance with state and federal regulatory requirements. This role requests documentation as needed to review and process determinations in accordance with policies and procedures. Additionally, the position may communicate with members and other internal and external customers in matters relating to appeals and/or grievances. Essential Responsibilities Receive and validate requests for appeals and/or grievances. Review appeals and/or grievances to ensure compliance with state and federal requirements. Communicate with members and providers in accordance with state and federal requirements as needed to complete requests. Locate or request necessary information from internal and external sources to complete appeals and/or grievance reviews. Cross-train on appeals, grievances, additional lines of business and other areas as needed. Maintain and track accurate and complete records and other documentation. Work with Quality Assurance clinicians, other CareOregon staff and delegated entities to ensure that appeals and/or grievance requests are managed in accordance with state and federal guidelines. Route appeals and/or grievance requests to the appropriate staff for additional review when needed. Create documents to share final resolution of appeal/grievance with members and/or providers. Prioritize and organize work to effectively meet strict deadlines as outlined by state and federal requirements; ask for assistance if uncertain of priorities. Responsible for consistently meeting high production and quality standards. Maintain confidentiality of all communications, records, and other data in accordance with HIPAA regulations, established quality management processes, and the highest professional standards. Collaborate with teams across the Clinical Operations department to ensure work and goals are met. Assist with gathering and assembling documentation and records needed for audits, external reviews, administrative hearings and internal committees. Organizational Responsibilities Perform work in alignment with the organization's mission, vision and values. Support the organization's commitment to equity, diversity and inclusion by fostering a culture of open mindedness, cultural awareness, compassion and respect for all individuals. Strive to meet annual business goals in support of the organization's strategic goals. Adhere to the organization's policies, procedures and other relevant compliance needs. Perform other duties as needed. Experience and/or Education Required Minimum 1 year experience providin