Medicare Appeals & Grievances Specialist

Job Description

Job Description

Medicare Appeals & Grievances Specialist

Location: Birmingham, AL

Work Schedule: Hybrid schedule with regular onsite presence at the VIVA HEALTH corporate office and some work-from-home opportunities.

Why VIVA HEALTH?

VIVA HEALTH, part of the renowned University of Alabama at Birmingham (UAB) Health System, is a health maintenance organization providing quality, accessible health care. Our employees are a part of the communities they serve and proudly partner with members on their healthcare journeys.

VIVA HEALTH has been recognized by Centers for Medicare & Medicaid Services (CMS) as a high-performing health plan, receiving a 5 out of 5 Star rating - the highest rating a Medicare Advantage Plan can achieve and has been repeatedly ranked as one of the nation's Best Places to Work by Modern Healthcare.

Benefits

• Comprehensive Health, Vision, and Dental Coverage
• 401(k) Savings Plan with company match and immediate vesting
• Paid Time Off (PTO)
• 9 Paid Holidays annually plus a Floating Holiday to use as you choose
• Tuition Assistance
• Flexible Spending Accounts
• Healthcare Reimbursement Account
• Paid Parental Leave
• Community Service Time Off
• Life Insurance and Disability Coverage
• Employee Wellness Program
• Training and Development Programs to develop new skills and reach career goals
• Employee Assistance Program

See more about the benefits of working at Viva Health -

Job Description

The Medicare Appeals & Grievances Specialist is responsible for intake of all Medicare appeals and grievances received from members, non-contracted providers, and government entities in a timely and accurate manner. This position will assist in processing the intake of appeals and grievances from mail, email, fax, and other electronic means and is responsible for ensuring appeals and grievances are entered correctly and timely into the department’s database system. Will assist in the coordination of a timely resolution according to federal and state guidelines and VIVA HEALTH policies and procedures.

Key Responsibilities

• Record appeals and grievances in the department’s system(s) timely and accurately, ensuring all necessary documentation is uploaded with the case.
• Classify member and non-contracted provider Medicare grievances and appeals according to federal and state regulations, also internal and organizational policies and procedures.
• Route appeals and grievances to other departments as needed for investigation to resolve the cases.
• Maintain production and quality goals in accordance with department metrics. Alert department leaders when an increase in volume might cause a backlog.

REQUIRED:

• High School Diploma or GED
• 1+ years’ experience working in managed care, healthcare customer service, or appeals and grievances
• Excellent written and verbal communication skills, interpersonal skills, organization skills, and the ability to handle multiple tasks
• Ability to carefully follow processes in sequential order
• Ability to meet established productivity, schedule adherence, and quality standards
• Attention to detail and ability to meet strict deadlines
• Ability to learn and use various computer platforms and ability to use applications of Microsoft Office
• Ability to use critical thinking skills to develop solutions to non-clinical issues using fact-based decision making
• Ability to work occasional planned and unplanned overtime to meet deadlines with minimal supervision

PREFERRED:

• Associate's Degree
• 1+ years’ experience processing Medicare appeals & grievances
• Knowledge of Medicare regulations
• Experience with administrative and/or coordinator positions with exposure to protected health information (PHI)