Appeal and Grievance Intake Coordinator - Remote AZ

Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. AZ Blue offers a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.

At AZ Blue, we have a hybrid workforce strategy, called Workability, that offers flexibility with how and where employees work. Our positions are classified as hybrid, onsite or remote. While the majority of our employees are hybrid, the following classifications drive our current minimum onsite requirements:

• Hybrid People Leaders: must reside in AZ, required to be onsite at least twice per week

• Hybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per week

• Hybrid 2 (Operational Roles such as but not limited to: Customer Service, Claims Processors, and Correspondence positions): must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per month

• Onsite: daily onsite requirement based on the essential functions of the job

• Remote: not held to onsite requirements, however, leadership can request presence onsite for business reasons including but not limited to staff meetings, one-on-ones, training, and team building

Please note that onsite requirements may change in the future, based on business need, and job responsibilities. Most employees should expect onsite requirements and at a minimum of once per week.

This remote work opportunity requires residency, and work to be performed, within the State of Arizona. 

PURPOSE OF THE JOB

Performs triage (intake, classification, case file setup and assignment) of Medicare Part C and D grievances and appeals; provides administrative, clerical, and other related support to the Grievance and Appeals (G&A) staff; establishes, maintains, and monitors grievance and appeal workload tracking and workflow processes; assists with maintaining regulatory compliance, timeliness requirements and ensuring accuracy standards are met; completes day-to-day operational tasks assigned according to defined processes and procedures; prepares G&A case file folders and assists with tracking and maintaining G&A case records and files; and assists with collecting and reporting G&A related performance and regulatory data.

QUALIFICATIONS

REQUIRED QUALIFICATIONS

Required Work Experience

• 2 years of experience in a Medicare Advantage (Part C) and Prescription Drug Benefit (Part D) insurance plan and/or other managed care organization.

• High school diploma or GED in general field of study.

Required Licenses

• N/A

Required Certifications

• N/A

PREFERRED QUALIFICATIONS

Preferred Work Experience

• 2 years of additional experience, including working knowledge of CMS Managed Care Manual Chapter 13 - Beneficiary Grievances, Organization Determinations, and Appeals and CMS Prescription Drug Benefit Manual Chapter 18 - Part D Enrollee Grievances, Coverage Determinations, and Appeals, knowledge of healthcare billing and claims adjudication processes

Preferred Education

• N/A

Preferred Licenses

• N/A

Preferred Certifications

• N/A

ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES

LEVEL I

• Receive, sort, classify, prioritize, manage, and distribute inbound G&A mail, fax, inter-office, and other correspondence according to policies and procedures, the CMS Managed Care and Prescription Drug Benefit Manuals, and other regulatory and procedural rules, guidelines and timeframes.
• Prepare and assign individual case files to the appropriate G&A staff, continuously update tracking logs, databases, and reports, monitor and manage case status, timelines, statistics, regulatory compliance and performance as required.
• Prepare and mail, fax, inter-office, and other outbound correspondence.
• Coordinate with enrolled members and providers submitting grievances and appeals to obtain additional information or clarification as required.
• Coordinate case files with G&A Staff (administrative evaluation of timely filing, claim payments, insufficient information, etc.), Quality Management staff (quality of care issues) Medical Dire