Grievance & Appeals Specialist III

Job Summary: The Grievance & Appeals Specialist III, in collaboration with department leadership, is responsible for processing and responding to claim appeals and disputes, and provides the department with subject matter expertise in clinical and code edit denials. Essential Functions: Review a variety of appeals including, but not limited to: high difficulty appeals, consent appeals, state complaints, dental appeals, low difficulty appeals, member and provider appeals, non-clinical appeals (i.e. tobacco surcharge, etc.), medically frail appeals, RCP appeals Prepare the appeals for clinical review and be responsible for recording and tracking on a regular basis Review submitted appeals daily for validation of the appeal Identify appropriate claim problem within the appeal Prepare all clinical edit appeals for review by computer research, print claim from Facets system, and print off all the code descriptions to assist the reviewer in decision making for committee meetings Maintain spreadsheet of all appeals reviewed with the outcomes resulting from the Appeals Committee Meetings Document within Facets the detailed information as to the outcome of the claim appeal Identify System changes, log the ticket and track the resolution Complete claim appeal through claim adjustments or letters of denials Interact with other departments such as Medical Management, Provider Operation, Provider Service Center and claims Review claim appeals for possible fraud and abuse and report to