Appeals & Grievances Case Coordinator

Health Net, Inc. (NYSE: HNT) is among the nation’s largest publicly traded managed health care companies.  Health Net’s mission is to help people be healthy, secure and comfortable.  The company’s POS, HMO, insured PPO, behavioral health and government contracts subsidiaries provide health benefits to more than 7 million individuals.  For more information on Health Net, Inc., please visit the company’s Web site at www.healthnet.com

 

JOB SUMMARY:


Resolves member grievances and appeals relative to quality of care, access to care and benefit determinations.

 

ESSENTIAL DUTIES AND RESPONSIBILITIES:

Ability to establish and maintain a cohesive relationship based on mutual trust and support with associates and external customers.

Meets established quality and productivity standards in al areas of appeal and grievance matters. This includes research, analysis, documentation, case summaries with recommendations for resolution, member education, formal letter composition and customer/partner telephone contact.

Prioritized and analyzes complex member issues, recognizing potential clinical care problems and seeks Medical Director and/or Clinical Specialist involvement to avoid or minimize risk when necessary.

Summarizes cases and determines appropriate methods for resolution of  member concerns in a timely and appropriate manner, and presents such information to Risk Assessment supervisor and/or appeals & Grievances Director for review.

Ensures the department is successful in meeting it’s goals and objectives that support the vital few within budget limitations.

Composes final letters that appropriately reflects the plan decision.

Interacts with the member to ensure resolution of plan recommendations.

Offers appropriate next steps to all unsatisfied members and assist them with the proper filing.

Leads by example in a manner that supports the company core values of Integrity, Quality, Respect, and Responsibility.
REQUIREMENTS


REQUIREMENTS:

 

Education:

College degree or additional experience providing an equivalent background required.

 

Certification/License:

 

Experience:

Three years previous experience in appeals and grievance resolution. Appeals & Grievances, Member Services and/or claims experience preferred

 

Knowledge, Skills & Abilities:

Strong organizational skills.

Must be able to work well with all levels in the organization.

Must be able to communicate with attorneys outside of the plan.

Medicare regulations and NCQA requirement knowledge and experience preferred.

Facilitation skills preferred.

Excellent oral and written communications skills with strong analytical and problem solving skills.

Able to operate PC-based software programs.

OR
Any combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position.





 

Health Net, Inc. supports a drug-free work environment and requires pre-employment background and drug screening.





 

Health Net and its subsidiaries are an Equal opportunity/Affirmative Action Employer M/F/V/D.