Enthusiastic Appeals & Grievance Coordinator with more than two years experience in a Health Insurance Company environment. Primarily focusing on Oregon Health Plan and Medicare member appeals and grievances. Skilled in receiving, routing, filing and delivering a wide range of medical documentation.
Effective time management
Written and verbal communication
Proficient in Microsoft Office Suite
Proficient in medical terminology
Knowledge of Medicaid and Medicare rules and regulations
Knowledge of OHP benefits
Understanding of prior-authorizations and claims/billing
Appeals & Grievance Coordinator, 10/2013 to 01/2016 AllCare Health Plan – Grants Pass, Oregon
Gather, analyze, and report documentation for verbal, written, and expedited member and provider complaints, grievances, appeals.
Input data and maintain records in various computer programs and databases.
Prepare and report documentation supporting verbal and written provider claims and pre-authorization appeals.
Coordinate and schedule Administrative Hearings between the Health Plan, Medical Assistance Program (MAP), Law Judge, provider, and member.
Received, processed, and routed medical record requests from various providers and venders.
Adhered to the strict guidelines and time frames set by the Medical Assistance Programs (MAP), The Centers of Medicare and Medicaid Services (CMS), Health Insurance Portability and Accountability Act (HIPAA), and the Health Plan.
Prepared resolution letters for member and provider appeals and grievances.
Interacted and communicated easily with department personnel, medical providers, and members.
Conducted and reported quarterly reports to The Medical Assistance Program (MAP).