Appeals & Grievances Analyst Job at MMM Holdings
LE0002 MMM Holdings, LLC
It's fun to work in a company where people truly BELIEVE in what they're doing!
We're committed to bringing passion and customer focus to the business.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Must be familiar with ASES contract in addition to the Enrollee Manual.
- Must be familiar in working complaints, Appeals (Standard and Expedites) and Grievance.
- Receives all member and provider requests and classifies the request as appeals, grievances, or complaints and creates new case file in A&G Electronic Systems.
- Create all types of A&G correspondence (Acknowledgement, Provider and Member No contact Letter, AOR, and Resolution letter, 14 days extensions, among others).
- Assist Appeals & Grievances Management in entering in the system the cases received.
- Sends appropriate notices to members and providers within established time frames according to member or provider request.
- Obtains necessary documentation from member, and provider.
- Must be able to work at a high pace, different types of cases maintaining a high quality.
- Maintains an updated chronology of how the case has been processed, while working the case.
- Contacts other departments for additional information such as but not limited to copies of claims, referrals, authorization or resolution.
- Refers cases to other departments for review or payment process.
- Analyzes and investigates the evidence according to the denial code and processes the case according to established policy. Once the investigation is completed the A&G Analyst will submit the administrative decision to the A&G Supervisor or designee. If the final decision requires a clinical evaluation it will be submitted to the Medical Director
- Consults appropriate personnel (physicians, Appeals and Grievance Manager or Appeals and Grievances Supervisor) to ensure appropriate handling of cases.
- Documents the resolution of all cases in the A&G application, department’s system, and PAU/Pharmacy/Claims system. For member appeal denials, prepares the file for review for an ALH within established timeframes.
- Reports on a weekly basis to Appeals and Grievances Supervisor. Stays informed of local and national developments in the policies and regulations that govern the complete processing of appeals and grievances.
- Maintain the manage case list worked a week in advanced in standard pre-service cases, 30 days in advanced for payment cases and 4 days in advanced in pharmacy cases. Expedites cases has to be worked in less than 24 hours.
- Coordinate Administrative Law Hearings with Management and Medical Director for appeal denial case presentation.
- Scores a high rate in internal and external monitoring and audits (98% of compliance rate).
- Be available for departments and company trainings and retraining.
- Working hours are from 7:30am-4:30pm, but must be available depending on the department’s needs on evening or weekend work, as necessary.
- Must be familiar with Milliman guidelines and able to apply the guidelines and document the cases accordingly as well as notify the member.
- Must comply with quote established by management; this can be adjusted based on departments’ necessity.
- Other tasks can be assigned as per A&G Management.
EDUCATIONAL EXPERIENCE
Two to three years in customer or provider service, or appeals and grievances experience and a Bachelor’s degree (B.A.) from a four year college or university; or equivalent combination of education and experience.
LANGUAGE SKILLS
Bilingual. Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and general public.
MATHEMATICAL SKILLS
Ability to calculate figures, and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference and volume. Ability to apply concepts of basic algebra and geometry. Ability to compute rate, ratio and percent and to draw and interpret bar graphs.
REASONING ABILITY
Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.
INTERPERSONAL RELATIONS
The responsibility of the person requires continuous interactions with others.
Internal Contacts
1. Directors
2. Managers
3. Supervisors
4. Employee Personal
External Contacts
1. ASES
2. OPP
3. Provider and (or) facilities
4. Members
GENERAL SKILLS
1. Ability to objectively analyze problems.
2. Investigative skills like the ability to gather evidence, document actions taken and organize the record of the investigation.
3. Follow through and persistence.
4. Substantial coordination with other departments of MMM.
5. Communication with physicians, other provider, and members.
6. Detailed oriented.
7. Ability to interpret complex government regulations.
8.. Skills in making presentations and coordinating meetings with Medical Director for review.
10. The ability to accomplish tasks with a minimum amount of direction.
11. Time Management Skills: ability to establish priorities and accomplish tasks in a timely and accurate manner.
12. The ability to multi task.
13. Computer Experience: Windows environment.
PHYSICAL AND MENTAL DEMANDS
Requires sitting and standing associated with normal office environment. Regularly talks and hears.
ENVIRONMENTAL AND WORKING CONDITIONS
Normal office environment. The noise is typically moderate. Evening or weekend work, as necessary.
This description is intended to provide only basic guidelines for meeting job requirements. Responsibilities, knowledge, skills, abilities and working conditions may change as needs evolve.
If you like wild growth and working with happy, enthusiastic over-achievers, you'll enjoy your career with us!
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