Job description

Specialist, Member Appeals & Grievances (In-Office)

Sonder Health Plans

• Full-Time

Job Description

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).

Job Type: Full-time

Pay: $60,000.00 - $68,000.00 per year

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

Experience level:

• 1 year

Shift:

• Morning shift

Weekly day range:

• Monday to Friday
• Weekend availability

Work setting:

• In-person
• Office

Ability to commute/relocate:

• Atlanta, GA 30339: Reliably commute or planning to relocate before starting work (Required)

Experience:

• Managed care appeals and grievances: 2 years (Required)
• Medicare claims denials and appeals processing: 2 years (Required)

License/Certification:

• LVN/LPN License (Preferred)

Work Location: One location

colinoncars.com is the go-to platform for job seekers looking for the best job postings from around the web. With a focus on quality, the platform guarantees that all job postings are from reliable sources and are up-to-date. It also offers a variety of tools to help users find the perfect job for them, such as searching by location and filtering by industry. Furthermore, colinoncars.com provides helpful resources like resume tips and career advice to give job seekers an edge in their search. With its commitment to quality and user-friendliness, colinoncars.com is the ideal place to find your next job.