Full-Time Coordinator, Grievance and Appeals

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.

Responsibilities:

• Administrate Standard and Expedited Appeals Processes as outlined in Client/Plan Sponsor Member Handbook and in compliance with applicable accrediting body standards, CMS and other state or federal regulatory requirements.
• Act as the primary investigator and contact person for member, prescriber or pharmacy grievances and appeals.
• Gather and provide documentation and research outcomes within required timeframes to Clients/Plan Sponsors who manage their own appeals
• Thoroughly document all action taken on behalf of the member to resolve the grievance/appeal
• Prepare and deliver statistics for required reporting
• Participate in audits, including document preparation and participation in on-site or remote audits, as a subject matter expert
• Abiding by HIPAA regulations and confidentiality requirements
• Educate and monitor compliance with complaint and appeal procedures
• Audit and provide oversight of upstream and downstream processes impacting complaints and appeals

Qualifications:

• High School Diploma or equivalent required. 2 years post high school education or bachelor’s degree preferred.
• CPhT certification or ability to obtain desired and preferred
• 2-3 years of managed care and/or insurance background in addition to a strong knowledge of CMS coverage determination and redetermination processes preferred
• Experience with CMS and/or NCQA audits strongly desired
• Proven success in documenting case files and managing multiple cases within requires timeframes desired

What is the last date for applying to the job?

Which countries are accepted for this remote job?