Job description
LE0002 MMM Holdings, LLC
It's fun to work in a company where people truly BELIEVE in what they're doing!
We're committed to bringing passion and customer focus to the business.
This position is responsible for receiving, investigating, gathering information and resolving member appeals, CTMs, inquiries and grievances, in addition to provider claim appeals and disputes, according to internal policy as well as the Centers for Medicare and Medicaid Services (CMS), NCQA (National Committee for Quality Assurance), and ASES (Administración de Seguros de Salud – for duals) regulations and time frames. To provide appropriate and timely processing of appeals and grievances, is essential in order to comply with Federal and Puerto Rico laws and regulations and improvement of member and provider satisfaction.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Receives all member and provider requests, classifies the request as appeals, grievances, initial determination, or inquiries and creates new case file in A&G Electronic Systems.
- Investigate and gather all information related to the complaint into the systems.
- Contact member or representative to obtain complete Appointment of Representative (AOR) Form, and provider to receive complete Waiver of Liability (WOL) Form. Send notices when verbal communication is not complete.
- Contact member, representative and provider involved in the case within CMS specific time frames for additional information, documentation or investigation.
- Investigate and document in AG System and CTM HPMS Module CTMs, within established time frame according to the priority classification.
- Refer any issue or deviation identified, such as but not limited to: FWA, PHI breech, quality of care clinical issue, contracting, billing, improper service, among others, to the correspondent department for their investigation.
- Create and upload in the system all types of A&G correspondence regarding case actions and /or resolutions to members or providers within established time frames according to member or provider request.
- Make follow up calls or written notifications, as applicable, to obtain necessary documentation from member such as but not limited to Authorization of Representative and Release of Medical Records forms, or from providers such as but not limited to Appeals Request form and Waiver of Liability.
- Refers cases to other departments (Pharmacy reimbursements, Dental, TNPR, or Claims) for review or payment process.
- Analyzes and investigates the evidence according to the denial code and processes the case according to established Medicare, Milliman, CMS policy.
- Once the investigation is completed, submits the administrative decision to the Supervisor or designee. If the final decision requires a clinical evaluation, it will be submitted to the Medical Director.
- Documents the resolution of all cases in the A&G application, department’s system, and PAU/Pharmacy system. When necessary, prepares the file for review by MAXIMUS Federal Services contracted independent review board within established time frames.
- Prepare and present appeals to Medical Director for determination; discuss case when necessary and additional information is required.
- Coordinate Administrative Law Hearings with Legal Advisor and Medical Director with Federal Judge for appeal denial case presentation.
- Other tasks can be assigned as per A&G Management.
EDUCATION AND EXPERIENCE
- Bachelor’s degree (B.A.) from a four-year college or university;
- 2 – 3 years prior experience in customer service or appeals and grievances.
- Must be familiar with the most recent CMS Appeals & Grievances Guidance in addition to the Independent Review Entity MAXIMUS Federal Services’ Manual.
- Must be familiar in working Inquiries, CTMs (complaints received through Medicare, OPP or SHIP), Member Appeals (Standard and Expedites), Non contracted provider Claim appeals and Grievance.
- Must be familiar with Medicare, Milliman, NCCG guidelines and able to apply the guidelines and document the cases accordingly as well as notify the member.
- Must stay informed of local and national developments in the policies and regulations that govern the complete processing of appeals and grievances.
GENERAL SKILLS
- Fully Bilingual: English and Spanish
- Investigative skills like the ability to gather evidence, document actions taken and organize the record of the investigation.
- Detailed oriented.
- Ability to interpret complex government regulations.
- Time Management Skills: ability to establish priorities and accomplish tasks in a timely and accurate manner.
- Multitask skills.
- Computer knowledge in programs such as: (Microsoft; Word, Excel, Power Point, Outlook, and ability in the keyboard).
- Must be able to work at a high pace, different types of cases maintaining a high quality, as required by the department’s monitoring and auditing protocols.
If you like wild growth and working with happy, enthusiastic over-achievers, you'll enjoy your career with us!
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