Avēsis
supplemental benefits
AppealsandGrievancesCoordinator
Neural analysis suggests this role is
optimal for Mid+ candidates.
“Appeals and Grievances Coordinator at Avēsis. Skills: Appeals and grievances process, medical records analysis, documentation, formal correspondence drafting, case management. completion of appeals and grievances from all states. reviews of member and provider appeals and grievances for dental and vision waiver services”
What You'll Achieve.
provide timely, accurate, and compliant resolution of dental and vision A&G cases within a regulated managed care environment.; ensure regulatory compliance
Industry & Context.
Decision making/problem solving skills; Critical Thinking: effectively troubleshoot complex issues, problem solve and multi-task.
Flexible to work alternating Saturday during holiday shifts as required., maintain internet service that allows you to complete your essential job duties without issue. Rates of 50 Mbps download and 10 Mbps upload while hardwired and not on a VPN are sufficient.
What They're Looking For.
Must Have
High school diploma or equivalent., 1+ years of exposure with medical, dental or vision terminology and/or coding (ICD-10, CDT, CPT)., 1+ years of experience with case management platforms or healthcare administrative systems, Working knowledge of medical, dental, or vision terminology and coding (ICD-10, CDT, CPT) relevant to the line of business., Proficiency in Microsoft Office Suite and experience with case management platforms or healthcare administrative systems., Ability to draft formal correspondence., Demonstrated understanding of HIPAA and the ability to handle protected health information in a compliant manner., Proven ability to manage a high-volume caseload, prioritize competing deadlines, and meet strict regulatory turnaround time requirements., attention to detail, critical thinking, and sound judgment with the ability to work both independently and collaboratively across departments., Flexible to work alternating Saturday during holiday shifts as required., As this role is a remote role, you are required to maintain internet service that allows you to complete your essential job duties without issue. Rates of 50 Mbps download and 10 Mbps upload while hardwired and not on a VPN are sufficient.
Nice to Have
1+ years of experience drafting adverse determination letters, supporting audit readiness, or working in managed care A&G case management platforms., Familiarity with applicable federal and state regulations governing appeals and grievances, including 42 CFR Parts 422 and 438 and NCQA standards., Registered Dental Hygienist or Dental Assistant credential
What You'll Do.
completion of appeals and grievances from all states
reviews of member and provider appeals and grievances for dental and vision waiver services
Analyze medical records
supporting documentation
and applicable guidelines to make informed decisions
Document rationale clearly and accurately in alignment with organizational and regulatory standards
Communicate outcomes effectively to members and providers.
Review and complete all provider appeals and grievances within required timeframes
Review and complete member appeals and grievances within required timeframes
plan documents and/or state guidelines when processing appeals or grievances
Issue administrative denials appropriately
Refer denials based on medical necessity to appropriate clinical staff
Collaborate with appropriate stakeholders to prepare all requests for Independent External Review when required
Participate in training programs to maintain functional expertise
Perform any other job duties as requested
Draft formal correspondence such as acknowledgement and resolution notices.
How You'll Work.
Team & Collaboration
collaborates with Claims, Provider Relations, Customer Service, and Clinical teams; contribute to team onboarding and knowledge sharing; Work closely with clinical teams as well as other internal operational areas to resolve complex cases.; Collaborate with appropriate stakeholders to prepare all requests for Independent External Review when required; Ability to work independently and within a team environment; Collaborative: ability to represent your own interests while being fair to those representing other or competing ideas in search of a workable solution for all parties.
Communication Scope
written and oral communication skills; Communicative: ability to relay issues, concepts, and ideas to others easily orally and in writing.
Full Job Description
# **Join us for an exciting career with the leading provider of supplemental benefits!** O**ur Promise** Through skill-building, leadership development and philanthropic opportunities, we provide opportunities to build communities and grow your career, surrounded by diverse colleagues with high ethical standards. The Appeals and Grievances Coordinator is the primary point of contact for members, providers, and clients throughout the appeals and grievances process. Although this role will report to the Supervisor, Appeals and Grievances, this individual will receive day-to-day performance support and case guidance from the A&G Team Lead. You will, provide timely, accurate, and compliant resolution of dental and vision A&G cases within a regulated managed care environment. The coordinator collaborates with Claims, Provider Relations, Customer Service, and Clinical teams, and is expected to contribute to team onboarding and knowledge sharing as their experience grows. **Functional:** * Responsible for the completion of appeals and grievances from all states * Perform reviews of member and provider appeals and grievances for dental and vision waiver services * Analyze medical records, supporting documentation, and applicable guidelines to make informed decisions * Document rationale clearly and accurately in alignment with organizational and regulatory standards * Work closely with clinical teams as well as other internal operational areas to resolve complex cases. * Communicate outcomes effectively to members and providers. * Review and complete all provider appeals and grievances within required timeframes * Review and complete member appeals and grievances within required timeframes * Apply Avesis policy, plan documents and/or state guidelines when processing appeals or grievances * Issue administrative denials appropriately * Refer denials based on medical necessity to appropriate clinical staff * Collaborate with appropriate stakeholders to prepare all requests for
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