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Positions in this function are responsible for setting up the Appeals and Grievance cases for the Coordinators, Nurses and Doctors to review for a determination of denial. Position consists of reading and analyzing the member's correspondence and determining what the complaint is which could lead to several different issues. The Clinical Appeals Representative needs to be able to distinguish between Quality of Care, Appeal, Grievances, Expedited, Claims, Referral issues and determining exactly what the member is wanting in their letters. Position involves, calling to obtain the correct information from Member, Medical Groups, Providers and other Departments. Position requires regulatory turnaround times. Accuracy is a very important part of this position.
- Receive appeal or grievance documentation and determine relevant details (e.g., what member is requesting)
- Make outbound calls to members and/or providers to clarify appeal or grievance information
- Determine where appeal or grievance should be reviewed / handled or route to other departments as appropriate
- Contact and work with other internal resources to obtain and clarify information
- Complete appeal or grievance review procedures according to relevant regulatory or contractual requirements, processes and timeframes