Appeals-Grievance Monitor Spec

  • Samaritan Health Services
  • 815 NW 9th St Corvallis Oregon 97330 United States
  • Posted: Feb 17, 2019
Full-time Professional

Job Description

  • JOB SUMMARY/PURPOSE
    • Responsible for ensuring that all appeals, member complaints, and grievances presented by providers, members, or their representatives are resolved in accordance with established policies and procedures, rules and regulations, prior to and during all internal and external audits. Serves as liaison between the Appeals and Grievance Department, Compliance Department, and various departments within the Samaritan Health Plans, as well as State or Federal Departments.
  • DEPARTMENT DESCRIPTION
    • Samaritan Health Plans is an Insurance Company that creates and delivers products and services that help build healthier communities. As part of an Integrated Delivery System, Samaritan Health Plans believes in giving members a greater role in their health and employers more options for their employees.
  • EXPERIENCE/EDUCATION/QUALIFICATIONS
    • High school diploma or equivalent required. Associate's degree or greater preferred.
    • Three (3) years working for an insurance plan or in the health field, working with medical and insurance terminology, required.
    • Two (2) years customer service background required.
    • Experience in Microsoft Office applications required.
    • Two (2) years experience in auditing insurance or medical files preferred.
    • Experience with Medicare and Medicaid preferred.
    • Experience in FACETS database and Crystal Reporting preferred.
  • KNOWLEDGE/SKILLS/ABILITIES
    • Effective written and verbal communication skills to perform group presentations, tactfully discuss issues, and listen to and understand concepts, rules and procedures. Ability to work with all levels within the organization, facilitate communication, and effectively document related activities.
    • Ability to identify complex problems, review related information, employ creativity and alternative thinking to develop and evaluate options and implement solutions.
    • Ability to organize, plan and prioritize work to complete within required time frames and to follow-up on pending issues. Ability to perform multiple tasks simultaneously and thrive in dynamic fast-paced environments and under pressure.
    • Knowledge of negotiation and ability to work with diverse groups in a challenging environment to accomplish objectives. Ability to cultivate positive and productive relationships within the Samaritan Health System as well as handle challenging situations and people.
    • Ability to represent the company in a professional manner and project a positive image in the community.
    • Knowledge and skills of research and technical writing. Ability to interpret, organize and edit written clinical and technical material for easy and practical use by clinical users.
  • PHYSICAL DEMANDS

Rarely
(1 - 10% of the time)

Occasionally
(11 - 33% of the time)

Frequently
(34 - 66% of the time)

Continually
(67 – 100% of the time)

CLIMB - STAIRS

LIFT (Floor to Waist: 0"-36") 0 - 20 Lbs

LIFT (Knee to chest: 24"-54") 0 – 20 Lbs

LIFT (Waist to Eye: up to 54") 0 - 20 Lbs

CARRY 1-handed, 0 - 20 pounds

BEND FORWARD at waist

KNEEL (on knees)

STAND

WALK – LEVEL SURFACE

ROTATE TRUNK Standing

REACH - Upward

PUSH (0 - 20 pounds force)

PULL (0 - 20 pounds force)

SIT

CARRY 2-handed, 0 - 20 pounds

ROTATE TRUNK Sitting

REACH - Forward

MANUAL DEXTERITY Hands/wrists

FINGER DEXTERITY

PINCH Fingers

GRASP Hand/Fist