Grievance and Appeals Coordinator - Remote

Overview

Navitus Health Solutions is seeking a Grievance and Appeals Coordinator to join our team!

The Navitus Grievance and Appeals process is an essential function to Navitus’ compliance with CMS regulations, accrediting body standards, other applicable regulatory requirements, and member expectations. The Navitus Grievance and Appeals department serves as the central repository for all complaints received by Navitus and all appeal requests where the responsibility has been delegated to Navitus. The Navitus Grievance & Appeals Coordinator serves to administrate the Navitus Grievance and Appeals processes as outlined by Client/Plan Sponsors, departmental policies and procedures, and regulatory standards. Coordinator, Grievance and Appeals serves as a liaison for Navitus members, prescribers and pharmacies regarding complaints or appeals related to denied pharmacy claims, membership and benefit issues, reimbursements and quality of care or service. Coordinator, Grievance and Appeals is responsible for presentation of the member appeals as required to the Medical Director, Center for Medicare/Medicaid Services, contracted reviewer, Client, and/or the contracted external review agency in accordance with applicable laws, organization policies, and regulatory requirements. Thorough research, documentation, and corrective action planning must be established for each respective case and effectuation completed in accordance with existing regulations, policies, and standards.

Is this you? Find out more below!

In Short

• Administrate Standard and Expedited Appeals Processes.
• Act as the primary investigator for member grievances and appeals.
• Gather and provide documentation to Clients/Plan Sponsors.
• Document all actions taken on behalf of members.
• Prepare and deliver statistics for required reporting.
• Participate in audits as a subject matter expert.
• Abide by HIPAA regulations and confidentiality requirements.
• Educate and monitor compliance with procedures.
• Audit and provide oversight of complaint processes.
• Other duties as assigned.

Requirements

• High School Diploma or equivalent required.
• 2-3 years of managed care or insurance background preferred.
• Experience with CMS and/or NCQA audits strongly desired.
• Proven success in documenting case files.
• Support compliance program objectives.
• Ability to interact cooperatively with other employees.

Benefits

• Top of the industry benefits for Health, Dental, and Vision insurance.
• 20 days paid time off.
• 4 weeks paid parental leave.
• 9 paid holidays.
• 401K company match of up to 5%.
• Adoption Assistance Program.
• Flexible Spending Account.
• Educational Assistance Plan.
• Referral Bonus Program – up to $750!