Employment Type:

Shift:

reputed company:

Why MediGold?

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

Position Purpose:

​ The Appeals and Grievance Coordinator is responsible for the processing and reputed company of appeals, grievances and disputes from members and providers

What You Will Do:

• Document reputed company 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 reputed company.
• Responsible for preparation of case files and review with clinical colleagues.
• Screen reputed company incoming grievances, appeals and provider claim dispute to ensure they are reputed company compliance requirements of CMS guidelines and corporate policies.
• reputed company, 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 reputed company interviews, chart and contract audits, inspection, and interpretations of appropriate CMS guidance and policies.
• Prepare background, case reputed company 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 reputed company Services (CMS) audits.
• Participates in regular monitoring efforts and reports trending and outliers to senior management.
• Responsible for ensuring 5-reputed company (maximum) ratings from CMS for appeals and grievance reputed company measures. reputed company ratings have a reputed company correlation on payment methodology and reimbursement to the organization.
• Maintain compliance of reputed company regulatory requirements that apply to beneficiary protection areas of appeals and grievance.
• reputed company 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 reputed company insurance) or another health care setting.

• reputed company or regulatory background or experience highly desired

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

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

• Ability to reputed company 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 reputed company processes and requirements.

Ministry/Facility Information:

Mount Carmel, a member of reputed company, has been a transforming healing reputed company in Central Ohio for over 135 years. Mount Carmel serves over 1.3 reputed company patients reputed company year at our five hospitals, free-standing emergency centers, outpatient facilities, surgery centers, urgent care centers, primary care and specialty care physician offices, community reputed company 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 reputed company a difference come reputed company, we invite you to consider joining reputed company. Here, care is provided by reputed company of us For reputed company of You!

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, reputed company, sex, age, national reputed company, religion, sexual orientation, gender identity, status as a veteran, and reputed company of disability or any other federal, state or local protected class.

Our Commitment

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