Grievance and Appeals Counselor

QUALIFICATIONS:

Education, skills and experience:

* High School Diploma required. A minimum of two years college or College Diploma preferred.

* Knowledge/Experience in the health care industry, preferably in public relations, Customer Service, social work or compliance/state & federal regulations preferred.

* Referral pre-certification, concurrent and post service experience preferred.

* Experience with a Managed Care Organization preferred.

* Experience with MC400 preferred.

* Strong computer skills, typing skills: Proficiency with Microsoft Word/Outlook preferred.

* Must be able to type a minimum of twenty (20) wpm with ninety (90) % accuracy.

* Strong organizational and time management skills.

* Must be capable of multitasking.

* Strong telephone, oral communications and customer service skills required. Must be able to diffuse difficult situations.

* Must be able to work efficiently, independently and with others in a multidisciplinary team.

* Must be flexible in meeting the demands of all department operations.

Bi-lingual a plus

POSITION SUMMARY:

Grievance and Appeals Counselor will act as a member advocate while at the same time presenting and justifying the organizations actions in relationship to individual grievance. The position will analyze, research, and respond appropriately to member/provider complaints/inquires in a timely manner. Reviews members' benefits package for coverage, limitations and exclusions. Gathers pertinent medical records and obtains guidelines, then matches the guideline to the medical records to determine if appropriate Clinical indications are met. The Counselor will contact social and regulatory agencies outside the FHCP and/or divisions within the organization in effort to address the member concerns. The position prepares the case for the clinical RN reviewer and/or Utilization Management Physician review. The position will accurately document research and outcomes in the Correspondence Unit Tracking system (CUT).