Regular
Non-Exempt
GENERAL DESCRIPTION:
Responsible for receiving and coordinating grievances and appeals submitted by participating providers concerning the administrative process for resolving prompt payment grievances in both the Classicare and Commercial lines of business. Supports the Senior Specialist in prompt payment grievances by investigating cases for resolution by the applicable regulations, guidelines, and contractual agreements.
ESSENTIAL FUNCTIONS:
Records and addresses payment grievances and appeals from participating company providers, as well as Open Negotiation notices from non-participating providers, and records them in the system and the logs required in the unit.
Classifies grievances and Open Negotiation notices by their specific line of business, ensuring compliance with applicable laws and regulations.
Prepares provider grievance or Open Negotiation files by creating files in the unit's shared folder and storing all relevant documents related to the grievances as necessary. Creates physical files if needed for any investigation process.
Validates in the hat providers meet regulatory requirements by checking their contractual status with the company, the status of claims filed as prompt payment grievances, whether these grievances are original or adjustments, and if they have been previously paid, among others.
Supports in the analysis, investigation, resolution, and response to grievances filed by participating providers based on the administrative procedure for resolving Prompt Payment Grievances and Open Negotiation notices. Makes acknowledgment, resolution, and/or dismissal letters as part of the resolution process of a prompt payment grievance and Open Negotiation.
Records all essential information from the investigation to reach a final decision in the system and case file.
Review grievance and appeal files to guarantee that all information related to grievances and appeals has been properly filed or identify errors in processing a grievance and notify of any findings.
Generate reports for the first ten claimant providers within the period specified by the petitioner, as required by regulatory agencies and other company departments.
Conducts searches within the system for information about the provider involved in the case. Collects and stores necessary information for the investigation and evaluation of the case, including it in the file that contains interventions with delegated entities.
Coordinates calls, faxes, training sessions, meetings, and correspondence with providers. Prepares requisitions for materials related to departmental grievance processes in collaboration with the assigned administrative assistant.
Contact providers and company personnel to validate grievance and appeal approaches, ensuring correct coordination in compliance with regulations, laws, and operational rules.
Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.
May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.
MINIMUM QUALIFICATIONS:
Education and Experience: Associate's Degree in Business Administration preferred. At least one (1) year of experience in claims, investigation, and/or customer/provider service.
OR
Education and Experience: Sixty to sixty-four of college credits in Business Administration preferred. At least one (1) year of experience in claims, investigation, and/or customer/provider service.
"Proven experience may be replaced by previously established requirements."
Certifications / Licenses: N/A
Other: N/A
Languages:
Spanish – Intermediate (comprehensive, writing and verbal)
English – Intermediate (comprehensive, writing and verbal)
''MCS Healthcare Holdings, LLC. (MCS) is an Equal Employment Opportunity Employer and take Affirmative Action to recruit Protected Veterans and Individuals with Disabilities. MCS is a participating E-Verify employer.''