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. Perform administrative tasks related to the resolution and closures of grievances and appeals.

Responsibilities:

• Intake and preparation of Dispute Files for External Review:
  
  
  
  • 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.
  
  
  
  
• Resolution of Disputes and Closure of Grievance and Appeals
  
  
  
  • For disputes: receive and/or monitor reports and portals for dispute decisions; update all applicable systems and notify delegates as applicable; review decision to confirm accuracy and append to the system; document decisions in CAG and 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.
  • For Grievances and Appeals: Perform administrative functions to close out Grievance and Appeal files; rout claims for adjustment; ensure validating adjustment was made correctly in accordance with the appeal decision; follow up with other business areas to ensure resolution actions were completed & document actions taken in CAG system.
  
  
  
  
• File Compliance
  
  
  
  • 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 and resolution of final appeal and grievance actions.
  • 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.