Member Services Grievances and Appeals Counselor

POSITION SUMMARY:

Member services Grievance and Appeals Counselor will act as a member advocate while at the same time presenting and justifying the organizations actions in relationship to individual grievance. The position will analyze, research, and respond appropriately to member/provider complaints/inquires in a timely manner. Reviews members' benefits package for coverage, limitations, and exclusions. Gathers pertinent medical records and obtains guidelines, then matches the guideline to the medical records to determine if appropriate Clinical indications are met. The counselor will contact social and regulatory agencies outside of FHCP and/or divisions within the organization in effort to address the member concerns. The position prepares the case for the clinical nurse reviewer and/or Utilization Management Physician review. The position will accurately document research and outcomes in the Correspondence Unit Tracking system (CUT). Must rotate for "On Call" coverage for afterhours, weekends & Holidays.

QUALIFICATIONS:

Education, skills and experience:

• High School Diploma required. A minimum two years of college or College Diploma preferred.
• Three (3) years' experiences in the health care industry, preferably in public relations, Customer Service, social work, or compliance/state & federal regulations preferred.
• Three (3) years' referral pre-certification, concurrent and post service experience preferred.
• Knowledge of case management, authorization of services or utilization review desirable.
• Five (5) years' experiences with a Managed Care Organization preferred.
• Knowledge of Medicare criteria and nationally recognized criteria preferred.
• Experience in Claims adjudication and benefit analysis preferred.
• Experience with MC400 preferred
• Working knowledge of ICD 10 and CPT coding preferred.
• Strong computer skills, typing skills: Proficiency with Microsoft Word/Outlook preferred.
• Must be able to type a minimum of twenty (20) wpm with ninety (90) % accuracy.
• Strong organizational and time management skills.
• Must be capable of multitasking.
• Strong telephone, oral communication and customer service skills required. Must be able to diffuse difficult situations.
• Must be able to work efficiently, independently and with others in a multidisciplinary team.
• Must be flexible in meeting the demands of all departmental operations.
• Bi-lingual a plus.