Specialist, Medicare Member Complaints, Appeals & Grievances (MCAG)

Sonder Health Plans Remote

Salary Range: $50,000 - $65,000 /yr # of positions: 1

Job Description

Job Summary Responsible for reviewing and resolving Medicare member complaints and appeals and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid (CMS). Knowledge/Skills/Abilities

· Responsible for intake, review, intervention and resolution of all complaints, appeals and grievances from Sonder members and related outside agencies, while maintaining confidentiality.

· Ensures all cases have been organized, categorized and reported correctly.

· Prioritize and organize tasks to meet compliance deadlines. Researches issues utilizing systems and clinical assessment skills, knowledge and approved "Decision Support Tools" in the decision making process. Requests and reviews complaint information from both Providers and Members including but not limited to, detailed bills/claims submissions, arguments for benefit coverage, medical records (with the appropriate clinical support staff), benefit materials and internal/external systems as appropriate.

· Evaluates for benefit coverage; formulates conclusions per protocol and collaborates with clinical staff, Medical Directors and other team members to determine response as appropriate.

· Analyzes work processes and identifies areas where procedures and quality could be improved

· Identifies root cause of complaints and provides applicable feedback to minimize member abrasion.

· Assures timeliness and appropriateness of responses in accordance with state, federal and Sonder Health Plans’ policies and procedures. Prepares complaints, appeals and grievance summaries, correspondence and documents information for tracking/trending data; assists in the preparation of case files to external review entities.

· Ability to meet established productivity, schedule adherence, and quality standards.

· Communicates with the management team to correct problems ensuring

· customer satisfaction.

· Reliably and consistently meets work schedules, productivity requirements and

· deadlines.

· Attends meetings as required; Participates in employee orientation and training.

· Performs and assists in other duties and special projects as required.

Job Qualifications Required Education High School Diploma or GED

Required Experience Medicare Managed Care complaints, appeals and grievances experience. Familiarity with Medicare claims denials and appeals processing, and CMS guidelines for appeals, denials, and grievances.

Preferred Education Associate's/Bachelor's Degree or minimum of 1 years' experience working with managed care plans.

Preferred Experience Any medical office experience

Experience with Centers for Medicare & Medicaid Services (CMS) systems and processes

Preferred License, Certification, Association LVN/LPN or completion of other healthcare related vocational program with certification (e.g., Certified Coder, billing, medical assistant).