Job Description

Employment Type:

Full time

Shift:

Why MediGold?

MediGold is a not-for-profit Medicare Advantage insurance plan serving seniors and other Medicare beneficiaries across the United States. We’re dedicated to providing excellent customer service, cost-effective care, and exceptional healthcare coverage. We rely on talented colleagues in a wide variety of professional roles including information technology, financial analysis, audit, provider relations and more.

Position Purpose:

​ T he Appeals and Grievance Coordinator is responsible for the processing and resolution of appeals, grievances and disputes from members and providers

What You Will Do:

• Document all appeal requests or grievances upon receipt in the operating systems and routes cases to appropriate clinical personnel for review.
• Obtain confidential medical records from providers offices utilizing secure methods.
• Responsible for preparation of case files and review with clinical colleagues.
• Screen all incoming grievances, appeals and provider claim dispute to ensure they are within compliance requirements of CMS guidelines and corporate policies.
• Gather, analyze and report verbal and written member and provider complaints, grievances and appeals in accordance with Federal regulations and time constraints.
• Conduct grievance and appeal investigations and provider claim dispute investigations through internal and external interviews, chart and contract audits, inspection, and interpretations of appropriate CMS guidance and policies.
• Prepare background, case summary and case files with records for submission to the Independent Review Entity (IRE) and ensures that cases are compliant and required timeframes are met.
• Obtain required documents and completely prepare cases for Appeals Committee (MAC) review, Administrative Law Judge (ALJ) Hearings.
• Prepares and reviews data universes for the Centers for Medicare and Medicaid Services (CMS) audits.
• Participates in regular monitoring efforts and reports trending and outliers to senior management.
• Responsible for ensuring 5-Star (maximum) ratings from CMS for appeals and grievance related measures. STAR ratings have a direct correlation on payment methodology and reimbursement to the organization.
• Maintain compliance of all regulatory requirements that apply to beneficiary protection areas of appeals and grievance.
• All other duties as assigned.

Minimum Qualifications:

• Education: Bachelor’s degree or an equivalent combination of education and experience.

• Experience: Three years of customer service experience or appeals and grievance experience, preferably in managed care (health insurance) or another health care setting.

• Legal or regulatory background or experience highly desired

• Strong written and verbal communication skills and demonstrated public speaker/educator desired.

• Ability to interpret and apply Federal law and regulatory requirements ensuring compliance with Medicare Managed care obligations.

• Ability to educate staff members, providers and enrollees about the appeals and grievance process.

• Familiarity with claims processing, coordination of benefits and use of claims processing system.

• Ability to follow Federal guidelines from CMS and Ohio Department of Insurance (ODI) for appeal and grievance resolution processes and requirements.

Position Highlights and Benefits:

• Competitive compensation and benefits packages including medical, dental, and vision with coverage starting on day one.
• Retirement savings account with employer match starting on day one.
• Generous paid time off programs.
• Employee recognition programs.
• Tuition/professional development reimbursement starting on day one.
• Relocation assistance (geographic and position restrictions apply).
• Discounted tuition and enrollment opportunities at the Mount Carmel College of Nursing.
• Employee Referral Rewards program.
• Mount Carmel offers DailyPay - if you’re hired as an eligible colleague, you’ll be able to see how much you’ve made every day and transfer your money any time before payday. You deserve to get paid every day!
• Opportunity to join Diversity, Equity, and Inclusion Colleague Resource Groups.

Ministry/Facility Information:

Mount Carmel, a member of Trinity Health, has been a transforming healing presence in Central Ohio for over 135 years. Mount Carmel serves over 1.3 million patients each year at our five hospitals, free-standing emergency centers, outpatient facilities, surgery centers, urgent care centers, primary care and specialty care physician offices, community outreach sites and homes across the region. Mount Carmel College of Nursing offers one of Ohio's largest undergraduate, graduate, and doctor of nursing programs. If you’re seeking a rewarding career where your purpose, passion, and desire to make a difference come alive, we invite you to consider joining our team. Here, care is provided by all of us For All of You!

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Mount Carmel and all its affiliates are proud to be equal opportunity employers. We do not discriminate on the basis of race, gender, religion, physical disability or any other classification protected under local, state or federal law.

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.