Primary City/State:

Arizona, Arizona

Department Name:

Grievances & Appeals

Work Shift:

Day

Job Category:

General Operations

Great careers are built at Banner. We understand that talented professionals appreciate having options. We are proud to offer our team members many career and lifestyle choices including remote & hybrid work options. Apply today.

 

Banner Plans & Networks (BPN) is a nationally recognized healthcare leader that integrates Medicare and private health plans. Our main goal is to reduce healthcare costs while keeping our members in optimal health. BPN is known for its innovative, collaborative, and team-oriented approach to healthcare. We offer diverse career opportunities, from entry-level to leadership positions, and extend our innovation to employment settings by including remote and hybrid opportunities.

In the role of Senior Grievance & Appeals Coordinator, you will utilize your expertise in Grievance & Appeals and Medicare to oversee diverse tasks and responsibilities, guaranteeing seamless departmental operations. Your duties will include reviewing incoming submissions, addressing urgent matters, conducting thorough case investigations and documentation, maintaining tracking systems, composing responses and decisions, conducting compliance audits, reporting on metrics, and leading training sessions.

The position is fully remote, with work hours from Monday to Friday, 8:00 a.m. to 5:00 p.m. in the Arizona Time Zone. Availability during some holidays may be necessary for compliance purposes. Residency in Arizona is a requirement for this role to ensure compliance.

Banner Health Network (BHN) is an accountable care organization that joins Arizona's largest health care provider, Banner Health, and an extensive network of primary care and specialty physicians to provide the most comprehensive healthcare solutions for Maricopa County and parts of Pinal County. Through BHN, known nationally as an innovative leader in new health care models, insurance plans and physicians are coming together to work collaboratively to keep members in optimal health, while reducing costs.

POSITION SUMMARY
This position supports the Grievance & Appeals Department by supporting the development of the team and by assisting in the preparation of the Health Plan in all State Hearings. This position is the standard by which each employee is to handle member and provider grievances, appeals and claim disputes. This position supports the development, implementation, maintenance and continuous improvement of the Grievance & Appeals department, programs and projects and assists the Grievance & Appeals Manager with day-to-day operations, ensuring production and quality standards according to contractual requirements.

CORE FUNCTIONS
1. Maintains State Fair Hearing Logs with appropriate information required by HP policy, AHCCCS, HCG and CMS regulations.

2. Reviews all State Fair Hearing requests by members and providers, pulls case files, meets with Grievance & Appeals Manager for further review and action which may include collaboration with others to avoid/reduce grievances, appeals and/or claim disputes. May attend State Fair Hearings.

3. Coordinates and assists the Grievance & Appeals Manager in preparing for higher level of appeals (i.e. Independent Review Entity reviews, hearings, etc.) including telephonic requests.

4. Assists with project management of departmental improvements. Coordinates with other departments on Grievance & Appeals projects/workgroups.

5. Assists the Marketing Department with the production of all member letters and notices. Participates actively in meetings, workgroups and committees relevant to the Grievance & Appeals process. May produces, prepare, quality check or deliver all reporting requirements in the absence of the Grievance & Appeals Manager.

6. Produces and analyzes weekly and monthly data to determine trends and provides recommendations for intervention. Assists with internal, external and self-audits of department and annual data validation.

7. Produces Monthly Operational Dashboard. Produces, analyzes and reports monthly data to ensure regulatory compliance. Updates Grievance & Appeals data in conjunction with the Marketing department on all HP websites.

8. Monitors and resolves member and provider expedited appeals and grievances received after hours and/or holidays when assigned to rotational on-call duty. Coordinates appropriate action by supporting clinical staff for processing of member and provider expedited appeals and/or grievances.

9. This position works under supervision, prioritizing data from multiple sources to provide quality care and support. Incumbents work in a fast-paced, sometimes stressful environment with a strong focus on customer service. Interacts with staff at all levels throughout the organization.

MINIMUM QUALIFICATIONS

Knowledge, skills and abilities as normally obtained through the completion of an Associate’s Degree in a Healthcare related field or business.

Three to four years of grievance and appeal work in a health care environment, or an equivalent combination of education and experience. Maintains knowledge of AHCCCS, HCG, and CMS regulations by participating in training, teleconferences and in-services.

Strong knowledge of administrative hearing processes for escalated grievances, appeals and claim disputes; Knowledge of Marketing Guidelines for AHCCCS, HCG and CMS. Knowledge of Health Plan policies, health care quality improvement initiatives and best practices, and program planning and project management best practices.

Skill in building and maintaining interpersonal relationships and preparing and presenting detailed information to ensure understanding for a wide audience base. Ability to plan/direct projects, grasp new knowledge and concepts quickly and apply them, and assign workflow and tasks to other employees as needed for training purposes. Ability to organize, follow through and report results of interventions, conduct Grievance & Appeals related meetings, workgroups and committees, and to work cross functionally across the organization. Ability to support Grievance & Appeals Manager’s work with attorneys, representatives and delegated persons regarding cases at the administrative hearing level. Ability to train new Grievance & Appeals coordinators, capable of mentoring trainees through a “buddy system”. Skill in developing and managing teams; demonstrated critical thinking in resolving issues and conflicts.

PREFERRED QUALIFICATIONS

Additional related education and/or experience preferred.

EEO Statement:

EEO/Female/Minority/Disability/Veterans

Our organization supports a drug-free work environment.

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