at Evolent Health in Springfield, Illinois, United States
Job Description
Your Future Evolves Here
Evolent partners with health plans and providers to achieve better outcomes for people with most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of fragmented health care system and ensure people get the same level of care and compassion we would want for our loved ones.
Evolent employees enjoy work/life balance, the flexibility to suit their work to their lives, and autonomy they need to get things done. We believe that people do their best work when they’re supported to live their best lives, and when they feel welcome to bring their whole selves to work. That’s one reason why diversity and inclusion are core to our business.
Join Evolent for the mission. Stay for the culture.
What You’ll Be Doing:
We are seeking a Grievance and Appeals Coordinator to be a key member of the team. The Grievance and Appeals Coordinator is responsible for receiving, investigating, and resolving member administrative appeals, grievances and provider administrative appeals and supporting the clinical team with clinical appeals. All tasks will be in compliance with regulatory and accrediting agency standards.
Collaboration Opportunities:
+ As a Coordinator, Appeals & Grievances, you will be working with an advanced team of coordinators that process Appeals & Grievances for several clients . Together the team maintains service level agreements for each client.
What You Will Be Doing:
+ Receive faxes, emails and mail to initiate an appeal or grievance request utilizing multiple software applications
+ Make outbound calls when necessary to obtain additional information pertaining to the research of an appeal or grievance
+ Triage & Assign cases amongst the team on a rotating basis
+ Collect, organize and track information received from a variety of resources to facilitate and expedite the processing of appeals and grievances
+ Generate acknowledgement letters for member appeals and grievances in accordance with regulatory standards
+ Initiate, research and resolve member grievances in accordance with company and regulatory standards
+ Initiate, research and refer member appeals to the Appeals RN
+ Initiate, research and resolve provider appeals or refer to the Appeals RN, as necessary
+ Generate resolution letters, as appropriate
+ Utilize multiple internal and external computer applications and programs
+ Meet established productivity and quality standards
+ Rotating Holiday coverage to intake emergent/urgent cases
+ Act as a back up coordinator
+ Perform other duties as assigned
Qualifications Required and Preferred:
+ 2 years of experience minimum in processing appeals and grievances – Required
+ 3 years of experience within a health plan, managed care organization or third-party administrator – Required
+ Understanding of appeals process and utilization management – Required
+ Working knowledge of regulatory and accreditation requirements - Preferred
+ Excellent verbal and written communication skills – Required
+ Experience in Medicaid with knowledge of NCQA guidance/regulations for appeal and grievance processing – Preferred
+ Bachelor’s Degree - Preferred
Technical Requirements:
We require that all employees have the following technical capability at their home: High speed internet over 10 Mbps and, specifically for all call center employees, the ability to plug in directly to the home internet router. These at-home technical requirements are subject to change with any scheduled re-opening of our office locations.
Evolent is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability status. If you need reasonable accommodation to access the information provided on this website, please contact recruiting@evolent.com for further assistance.
The expected base salary/wage range for this position is $$19-25/hr. This position is also eligible for a bonus component that would be dependent on pre-defined performance factors. As part of our total compensation package, Evolent is proud to offer comprehensive benefits to qualifying employees. All compensation determinations are based on the skills and experience required for the position and commensurate with experience of selected individuals, which may vary above and below the stated amounts.
