Grievance & Appeals Dispute Specialist

Summary of Job

Process disputes submitted by contracted and non-contracted providers. Types of correspondence handled by the individual will include, but is not limited to; correspondence, HQSI/ESMSEF appeals and Cotiviti disputes. Provide technical and administrative support to Grievance and Appeals dept. to ensure that departmental goals are met.

Responsibilities:

• Facilitate the dispute review: submit appeal packet via UPS or dispute agent portal, as applicable.
• For Contracted Facility Dispute Resolution Agent (DRA) requests, provide email notification to the contacted facility, notifying them that the request has been submitted to the DRA.
• Intake disputes and compile "dispute" packets for submission to either the DRA agent or Cotiviti.
• Review new dispute receipts to confirm request is valid and to identify the appropriate dispute agent. If request is invalid, notify the provider in writing with the reasons why the request is not valid.
• Prepare disputes for external review, reviewing the previous appeal files as applicable and compiling all applicable documents to create the dispute packet.
• Receive dispute decision, updating all applicable systems and notifying delegates as applicable.
• Monitor email and the dispute agent portal for decisions.
• Review decision to confirm accuracy and append to the system.
• Document decisions in CAG; notify the Sr. Medical Clerk (SMC) to update the care management system as applicable.
• For delegate cases, notify the applicable delegate of the decision via email.
• If decision is overturned, the Dispute Specialist will reach out to claims to facilitate the effectuation of the decision.
• Ensure timeframes are met and files are completed per G&A operational policies and procedures.
• Monitor daily and weekly pending reports and CAG work list to ensure timely submission of files.
• Classify/code CAG inquiries appropriately, entering all actions taken in investigation for auditing & reporting purposes.
• Make follow-up calls to provider or reach out to the dispute agent via email for any additional information.
• Liaison with Claims to ensure determinations are effectuated within stringent timeframes.
• Regular attendance is an essential function of the job.
• Perform other duties as assigned or required.