Specialist, Member Appeal and Grievances

Qualifications

• Managed care appeals and grievances: 2 years (Required)
• Medicare claims denials and appeals processing: 2 years (Required)
• LVN/LPN License (Preferred)

Job Summary

Responsible for leading, organizing and directing the activities of the Grievance and Appeals Unit that is responsible for reviewing and resolving member complaints and appeals and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid (CMS).

Knowledge/Skills/Abilities

• Responsible for submission, intervention and resolution of appeals and grievances from Sonder members and related outside agencies.
• Researches issues utilizing systems and clinical assessment skills, knowledge and approved “Decision Support Tools” in the decision making process regarding health care services and care provided to members.
• Requests and reviews medical records, notes, and/or detailed bills as appropriate; evaluates for medical necessity and appropriate levels of care; formulates conclusions per protocol and collaborates with Medical Directors and other team members to determine response; assures timeliness and appropriateness of responses per state, federal and Sonder Health Plans’ policies and procedures.
• Prepares appeal summaries, correspondence and documents information for tracking/trending data; assists in the preparation of narratives, graphs, flowcharts, etc. for presentations and audits.

Job Qualifications

Required Education

High School Diploma or GED

Required Experience

• Managed care appeals and grievances experience.
• Familiarity with Medicare claims denials and appeals processing, and CMS guidelines for appeals, denials, and grievances.

Preferred Education

Associate’s/Bachelor’s Degree or minimum of 1 years’ experience working with managed care plans.

Preferred Experience

N/A

Preferred License, Certification, Association

LVN/LPN or completion of other healthcare related vocational program with certification (e.g., Certified Coder, billing, medical assistant).