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HCS Job Title: Grievance and Appeals Coordinator
Company Job Title: Grievance and Appeals Coordinator 1

Working with Hiring Manager Sachiko Burns and Staffing Specialist Teresa Baker

Req: 122005-1
No Griffin

Vaccination NOT REQUIRED
# of Openings: 1 pos, 1 sub spot

If Contract, Length of Assignment: RTH
MU or BR: 40% MU
Compensation Notes: $20 to $20 an hour
Location: Hybrid in Columbus - This role will be hybrid. For the first month, the employee would work from the office so as to learn the in-office task. Eventually, we would offer more hybrid opportunities once they become familiar with the remote task.
Shift: Mon-Fri 8-5
Start Date: ASAP
Interview Times/Interviewer: Virtual with Herman Nkwate and Sachiko Burns
Minimum Education/Licensures/Qualifications:
Please include city, state on resume

1+ years of recent Grievance, appeals, denials or medical billing experience in health plan setting
Strong job tenure, they don’t want jumpy candidates for this role
Basic Excel, advance Word Skills
HS Diploma or GED

Soft Skills Required:

Detailed oriented and able to multi task
Strong analytical and communication skills
Work independently and prioritized assigned task

Preferred but not a must:

Ability to adhere to strict TAT (Turn around Times)
Ability to communicate with multiple departments
Associates degree

Types of Candidates to Submit to Sales Rep:
Best Candidate: Grievance, Appeals, or Denials Specialist with 2+ years in managed care
Second Best Candidate: Grievance, Appeals, or Denials Specialist with 2+ years in 3rd party setting
Third Best Candidate: Claims or billing Specialist with 2+ years in managed care or any healthcare setting

Day to Day Duties:
Pulling appeals from the workbasket, reviewing claim denials, setting up cases for nurse reviews, sending out provider notification letters and building authorizations using CPT codes.

Receive hard copy mail/scan loaded prepare for appeals.

Describe the performance expectations/metrics for this individual and their team:
Hourly performance is tracked. Building 2 to 3 cases per hour.

Tell me about what their first day looks like: Mandatory trainings, system set-ups and touch-base with management or a team personnel.

What previous job titles or background work will in this role? Denial coordinator, claims specialist, grievance and appeals coordinator, provider service reps, customer service, managed care organization experience

Sample Resume:

Brandy Staccato
Hillard, Oh 43026

Relevant Skills Set

Proficient in ICD-9/10-CM, CPT, HCPCS coding systems
Extensive knowledge of risk adjustment methodologies and CMS guideline
Strong understanding of medical coding and documentation best practices
Experience in conducting audits and compliance reviews
Excellent attention to detail and ability to identify coding errors and discrepancies
Proficient in using coding software and electronic health record (EHR) systems
Strong analytical and problem-solving skills
Effective communication and interpersonal abilities
Ability to work independently and collaboratively within a team
Experienced Medical Auditor with a comprehensive understanding of healthcare regulations and coding guidelines

Professional Experience:
Cavohealth
03/2021 - Present
Medical Coding Risk Adjustment and Auditor

Perform comprehensive audits of medical records, coding and documentation to identify areas of risk and compliance issues.
Review and assess coding accuracy, completeness, and adherence to coding guidelines, policies and regulatory requirements.
Conduct internal and external audit to ensure compliance with CMS guidelines, HCC coding, and risk adjustments methodologies.
Prepare detailed reports and documentation of audit findings, including recommendations for corrective actions.
Stay up to date with changes in coding guidelines, regulations, and reimbursement policies.
Assist in developing and implementing coding education and training programs for coding staff and providers.
Collaborate with physicians, coders and other healthcare professionals to educate and provide feedback on coding and documentation improvement opportunities.

Arcadia Recovery
05/2018 - 02/2021
Medical Billing and Coding

Accurately assigned ICD-9/10-CM, CPT, and HCPCS codes to medical records based on documentation and coding guidelines.

Conducted regular audit of coded records to ensure compliance and accuracy.
Collaborated with physicians and healthcare professionals to clarify documentation and obtain additional information when necessary.
Assisted in the development and implementation of coding policies and procedures.
Participated in coding team meetings and educational sessions to enhance coding knowledge and skills.

Additional Experience
CSI HANSON OARS Columbus, OH 8/2011 to 1/2013
Payroll & Accounting

BIPIN SHAH MD., Columbus, OH 12/2008 to 8/2011
Medical Billing Manager

NESCO ACCOUNTING AND FINANCE, Westerville, OH 11/2007 to 12/2008
Progressive Medical Inc. Accounts Receivable and Pharmacy Biller

Education
American Academy pf Professional Coders. (CPC)
Medical Practice Manager (Medical Billing and Account Receivable)

Education
American Academy pf Professional Coders. (CPC)
Medical Practice Manager (Medical Billing and Account Receivable)

Summary: Analyze and resolve verbal and written claims and authorization appeals from providers and pursue resolution of formal grievances from members.Job Responsibilities: Gather, analyze and report verbal and written member and provider complaints, grievances and appeals Prepare response letters for member and provider complaints, grievances and appeals Maintain files on individual appeals and grievances May coordinate the Grievance and Appeals Committee Support the pay-for-performance programs, including data entry, tracking, organizing, and researching information Assist with HEDIS production functions including data entry, calls to providers offices, and claims research. Manage large volumes of documents including copying, faxing and scanning incoming mailEducation/Experience: High school diploma or equivalent. Associates degree preferred.0-2 years of experience

Billing/Claims/Appeals

$23/hr

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