• Job Description

  Req#: 32298

  Job Summary
  The primary responsibilities of a Medicare Appeals and Grievances Coordinator are centered on daily resolution of Medicare member, member's representatives (which can be a treating physician) and non-participating provider's appeals and grievances in compliance with applicable CMS timeframes and regulations. The Medicare Appeals & Grievances Coordinator is accountable for inventory prioritization of case load to meet various CMS and OIR required SLAs, gathering applicable information related to the case, working with appellants and delegated vendors to obtain for medical records, tracking effectuations, and meeting strict written and oral notification requirements.

  Essential Functions

  • The essential functions listed represent the major duties of this role, additional duties may be assigned.
  • Review appeal and grievance cases from various appellant types (member, member representative, treating physician and non-participating providers) in accordance with CMS regulatory guidelines and timeframes. Must ensure cases are classified correctly and reviewed for potential expedited requests.
  • Resolves complex standard or expedited grievances, appeals or disputes involving expressions of dissatisfaction, reimbursement, medical necessity, Utilization Management and benefits from the various appellant types (member, member representative, treating physician and non-participating providers) in accordance with CMS regulatory guidelines and timeframes.
  • Prioritize case workload to ensure CMS timeframes and required written notifications are met for various case types:
    
    • Standard Pre-Service Appeals – 30 day SLA – written notification required
    
    • Expedited Pre- Service Appeals – 72hrs SLA – written notification required
    
    • Post Service appeals – 60 day SLA – written notification required
    
    • Payment Disputes – 30 day SLA – written notification required
    
    • MA Grievances – 30 day SLA – written notification required
    
    • Med Supp Grievances – 60 day SLA – written notification required
    
    
  • Access various systems such as: MAAGC, JIVA, Diamond, Siebel, ProviderConnect, Client Letter, ERCMS RADMD, Magellan, and Blue 2 in order to gather pertinent data related to the case and document resolution.
  • Conduct a thorough research and accurately document pertinent details to include research details, action taken for resolution or outreach to various business partners and attach supporting documents to the case
  • Coordinates with internal business partners and provides case details, gathers required data or medical records for cases related to clinical decisions, delegated vendors, claims, network, etc.
  • Ensure proper research is completed with documentation of supporting details to render a final determination with verbal and/or written notification to the appellant within the CMS timeframes
  • Perform outreach to members, providers, internal and external business partners in order to complete resolution of appeal or grievance (10%)
  • Facilitates escalated calls and issues from providers and/or members regarding appeals or dispute decisions. Escalates any issues or phone calls to the Manager as needed.

  
  Qualifications

  Required Work Experience
  3+ years related work experience. Experience Details: Experience in Member Contact, Enrollment, Maintenance and Billing (EM&B), Claims or Medicare experience.

  Required Management Experience
  No supervisory/management experience required

  Required Education
  High school diploma or GED

  Additional Required Qualifications
  
  Experience using Siebel, Diamond, JIVA and other Medicare databases.
  Ability to work flexible schedule with overtime and weekends when needed
  Medicare product knowledge
  Ability to work independently and collaboratively as a team member
  Excellent interpersonal skills and an ability to recognize, understand, and respond to sensitive member issues or concerns
  Ability to manage multiple priorities, have analytical and problem solving skills with attention to detail

  Preferred Education
  Bachelor’s degree

  Additional Preferred Qualifications
  Strong working knowledge of Medicare Advantage/ Supplement/ Frozen Products, CMS, OIR, DFS and other regulatory requirements Proven organizational skills with strong attention to detail Proven ability to work independently, collaboratively and use appropriate judgment to make independent decisions by following guidelines Intermediate PC skills (MS Word, Excel, PowerPoint) Hands-on experience processing Medicare Claims, Written Inquiries or EMB transactions Current Experience with JIVA, Diamond, Siebel, ProviderConnect, CustomerConnectClient Letter, ERCMS RADMD, Magellan, and Blue 2

  General Physical Demands
  Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.
  
  
  What We Offer:
  As a Florida Blue employee, you will thrive in our Be Well, Work Well, GuideWell culture where being well as an individual, and working well as a team, are both important in serving our members and communities.
  
  To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to:

  • Medical, dental, vision, life and global travel health insurance;
  • Income protection benefits: life insurance, Short- and long-term disability programs;
  • Leave programs to support personal circumstances;
  • Retirement Savings Plan includes employer contribution and employer match;
  • Paid time off, volunteer time off, and 11 holidays
  • Additional voluntary benefits available; and
  • A comprehensive wellness program

  
  Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ.
  
  To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases.
  
  Hourly Pay Range: $19 - $31
  
  Typical Hourly Pay Range: $19 - $24
  
  Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring.
  
  We are an Equal Opportunity/Protected Veteran/Disabled Employer committed to creating a diverse, inclusive and equitable culture for our employees and communities.

• About the company

  Florida Blue offers affordable health insurance plans to individuals, families, and businesses. Explore our medical, dental, and Medicare health care plans.

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