AmeriHealth Caritas
Your career starts now. We are looking for the next generation of healthcare leaders.
At AmeriHealth Caritas, we are passionate about helping people get care, stay well, and build healthy communities. As one of the nation's leaders in healthcare solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services, and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we would like to hear from you.
Headquartered in Newtown Square, Pennsylvania, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.
Discover more about us at www.amerihealthcaritas.com.
Responsibilities:
Reporting to the Supervisor, Appeals and Grievances, this position is responsible for the administrative tasks for coordination of member and/or provider appeals, the analysis of claims and appeals, and the review of medical management authorizations.;
Research and Investigate member and/or provider appeals and grievance requests, including review of UM/claim denial reasons, contract/regulatory rules, benefits, and documentation received on appeal/grievance
Distribute meeting materials, reports, and follow-up documentation as needed.
;
Facilitate, Manage, and guide panel meetings (i.e., telephonic, video conference and in-person) by enforcing guidelines, fostering order and engagement, and ensuring smooth and cohesive discussion.
Communicate effectively with panel members, stakeholders, and leadership to ensure alignment and clarity of appeal(s).
Maintain confidentiality, organization, and integrity in handling sensitive information.
Upload recording, documentation, and transcription to capture key discussions and decisions.
Outreach call(s) made to members/participants, providers and /or member/participant representatives, to acknowledge receipt of appeal/grievance and discuss intent of appeal/grievance
Explain the appeal/grievance process including helping members understand the outcome and implication of appeals decisions
Prepares case file (original denial, all information received on appeal, medical records, etc.)
Schedule participant/member for committee panel sends scheduling letter if needed
Prepares, develops and presents written case summaries, if needed and process dictates, for all adverse determination for the purpose of conducting State Fair Hearings
Prepare and send cases files to other teams as needed (e.g. legal, external appeals, state fair hearings, etc.)
Communicates updates and status of outstanding member and provider complaints/issues to management
Monitors to ensure that all problems with appeals/grievances presented by plan members/participants are resolved in accordance with established policies and procedures
Update and/or generate authorization updates requests, for services that have been appealed
Maintains accurate, timely, and complete record of appeals and grievances in the appeals system and documents, all correspondence with a member/participant, representative and/or a provider, related to an appeal or grievance issue
Maintains quality and compliance standards ;as dictated by the state and federal entities
Maintains contractual agreements with participating providers related to appeals and grievances
Monitors caseload daily to ensure all cases are kept within compliance; follows up and escalates when compliance standards are at risk
Actively seeks the involvement of the legal department or compliance department, as necessary, for clarification and supporting documentation by escalating issues to appeals and grievances management
Obtain authorization for release of sensitive and confidential information
Keeps current with rules, regulations, policies and procedures relating to Plan member benefits, member's rights and responsibilities, and Complaints and Grievances
Ensure case file is sent to appropriate committee for decision making or example, internal committee/panel, independent review organization, internal medical director - as process dictates
Provide support presenting cases and facilitating committee meetings as needed
Send appeal to an independent review organization portal, for those appeals that require an external match specialty review
Obtain data from multiple systems/vendors to ensure all documentation needed for appeal is obtained, for e.g. PerformRX, LTSS and other systems/vendors as needed
Collaboration with internal counterparts as needed to ensure proper handling of the appeal e.g. UM team, medical directors, claims, contact center, vendors as needed (e.g. PerformRX)
Creates decision letter with detail description of the nature of appeal / grievance including rational for the decision and options for moving forward
Initiate and follow up on effectuations (um authorization update/claim adjustment) for overturned appeals/grievances
Education/ Experience:;
Required High School/GED
Required a minimum of two (2) years' work experience in a Managed Care environment
1 to 3 years' experience in grievance/appeals environment required
The Ideal Person will have:
Proven experience as a facilitator or moderator /similar
Experience organizing and managing meetings.
Excellent verbal and written communication skills
Ability to engage and manage diverse groups.
Awareness and sensitivity to diverse cultural backgrounds
Ability to create a positive environment.
Ability to handle challenging situations and conflict constructively.
Familiarity with presentation software, video conferencing tools;;; ( Zoom & Team) and relevant technology
Proficiency with Windows and Microsoft Office applications, including Excel, Access, PowerPoint and Outlook
Knowledge of the basic health care industry, managed care principles, claims, and medical terminology
Ability to work collaboratively or independently; deliver high-quality work; attention to detail and flexibility; excellent verbal and written communication skills communication skills
Our Comprehensive Benefits Package
Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.
As a company, we support internal diversity through:
Recruiting. We are an equal opportunity employer. We do not discriminate on the basis of age, race, ethnicity, gender, religion, sexual orientation, or disability. Our inclusive, equitable approach to recruiting and hiring reinforces our commitment to DEI.
At AmeriHealth Caritas, we are passionate about helping people get care, stay well, and build healthy communities. As one of the nation's leaders in healthcare solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services, and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we would like to hear from you.
Headquartered in Newtown Square, Pennsylvania, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.
Discover more about us at www.amerihealthcaritas.com.
Responsibilities:
Reporting to the Supervisor, Appeals and Grievances, this position is responsible for the administrative tasks for coordination of member and/or provider appeals, the analysis of claims and appeals, and the review of medical management authorizations.;
Research and Investigate member and/or provider appeals and grievance requests, including review of UM/claim denial reasons, contract/regulatory rules, benefits, and documentation received on appeal/grievance
Distribute meeting materials, reports, and follow-up documentation as needed.
;
Facilitate, Manage, and guide panel meetings (i.e., telephonic, video conference and in-person) by enforcing guidelines, fostering order and engagement, and ensuring smooth and cohesive discussion.
Communicate effectively with panel members, stakeholders, and leadership to ensure alignment and clarity of appeal(s).
Maintain confidentiality, organization, and integrity in handling sensitive information.
Upload recording, documentation, and transcription to capture key discussions and decisions.
Outreach call(s) made to members/participants, providers and /or member/participant representatives, to acknowledge receipt of appeal/grievance and discuss intent of appeal/grievance
Explain the appeal/grievance process including helping members understand the outcome and implication of appeals decisions
Prepares case file (original denial, all information received on appeal, medical records, etc.)
Schedule participant/member for committee panel sends scheduling letter if needed
Prepares, develops and presents written case summaries, if needed and process dictates, for all adverse determination for the purpose of conducting State Fair Hearings
Prepare and send cases files to other teams as needed (e.g. legal, external appeals, state fair hearings, etc.)
Communicates updates and status of outstanding member and provider complaints/issues to management
Monitors to ensure that all problems with appeals/grievances presented by plan members/participants are resolved in accordance with established policies and procedures
Update and/or generate authorization updates requests, for services that have been appealed
Maintains accurate, timely, and complete record of appeals and grievances in the appeals system and documents, all correspondence with a member/participant, representative and/or a provider, related to an appeal or grievance issue
Maintains quality and compliance standards ;as dictated by the state and federal entities
Maintains contractual agreements with participating providers related to appeals and grievances
Monitors caseload daily to ensure all cases are kept within compliance; follows up and escalates when compliance standards are at risk
Actively seeks the involvement of the legal department or compliance department, as necessary, for clarification and supporting documentation by escalating issues to appeals and grievances management
Obtain authorization for release of sensitive and confidential information
Keeps current with rules, regulations, policies and procedures relating to Plan member benefits, member's rights and responsibilities, and Complaints and Grievances
Ensure case file is sent to appropriate committee for decision making or example, internal committee/panel, independent review organization, internal medical director - as process dictates
Provide support presenting cases and facilitating committee meetings as needed
Send appeal to an independent review organization portal, for those appeals that require an external match specialty review
Obtain data from multiple systems/vendors to ensure all documentation needed for appeal is obtained, for e.g. PerformRX, LTSS and other systems/vendors as needed
Collaboration with internal counterparts as needed to ensure proper handling of the appeal e.g. UM team, medical directors, claims, contact center, vendors as needed (e.g. PerformRX)
Creates decision letter with detail description of the nature of appeal / grievance including rational for the decision and options for moving forward
Initiate and follow up on effectuations (um authorization update/claim adjustment) for overturned appeals/grievances
Education/ Experience:;
Required High School/GED
Required a minimum of two (2) years' work experience in a Managed Care environment
1 to 3 years' experience in grievance/appeals environment required
The Ideal Person will have:
Proven experience as a facilitator or moderator /similar
Experience organizing and managing meetings.
Excellent verbal and written communication skills
Ability to engage and manage diverse groups.
Awareness and sensitivity to diverse cultural backgrounds
Ability to create a positive environment.
Ability to handle challenging situations and conflict constructively.
Familiarity with presentation software, video conferencing tools;;; ( Zoom & Team) and relevant technology
Proficiency with Windows and Microsoft Office applications, including Excel, Access, PowerPoint and Outlook
Knowledge of the basic health care industry, managed care principles, claims, and medical terminology
Ability to work collaboratively or independently; deliver high-quality work; attention to detail and flexibility; excellent verbal and written communication skills communication skills
Our Comprehensive Benefits Package
Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.
As a company, we support internal diversity through:
Recruiting. We are an equal opportunity employer. We do not discriminate on the basis of age, race, ethnicity, gender, religion, sexual orientation, or disability. Our inclusive, equitable approach to recruiting and hiring reinforces our commitment to DEI.