Appeals and Grievance Analyst
PacificSource

Looking for a way to make an impact and help people?

Join PacificSource and help our members access quality, affordable care!

PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.

Diversity and Inclusion: PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.

Position Overview: Prepare, analyze, and complete appeals and grievance processes meeting internal, state and federal regulations. Organize state and federal hearings and provide administrative testimony on behalf of PacificSource. Submit reports and case write ups to external entities as determined by state or federal regulations. Support member and provider experience.

Essential Responsibilities:

• Oversee, coordinate, and execute all Appeal and Grievance response and resolution as required within PacificSource policy, best practice, State and Federal Regulation
• Perform thorough investigations utilizing critical thinking, and root cause evaluation methods to make informed and justified administrative decisions on behalf of PacificSource
• Generate technically precise case files to external facing entities as required by regulation or requested as needed
• Coordinate and execute external review and hearing processes provided to members under applicable State and or Federal regulations.
• Provide testimony on behalf of PacificSource within the scope of Medicaid and/Medicare appeals processes
• Service as mentor and subject matter expert to A&G team members to help support development and collaboration

Supporting Responsibilities:

• Provide support and information to Reporting Specialist upon request.
• Provide adhoc reporting as requested by Team Lead or Manager.
• Meet department and company performance and attendance expectations.
• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Perform other duties as assigned.

Work Experience:

• Minimum of three years customer service, claims processing or insurance industry experience required.
• Minimum of 1 year of experience with technical writing and conflict resolution required.

Education, Certificates, Licenses: Bachelor degree or equivalent work experience required.

Knowledge:

• Requires strong research, analytical and data entry skills.
• Experience using Facets, Onbase, and other software packages used by PacificSource is strongly preferred.
• Must have basic math skills, the ability to work under strict deadlines, and excellent organizational skills.

Competencies

• Adaptability
• Building Customer Loyalty
• Building Strategic Work Relationships
• Building Trust
• Continuous Improvement
• Work Standards
• Contributing to Team Success
• Planning and Organizing

Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5% of the time.

Our Values

We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:

• We are committed to doing the right thing.
• We are one team working toward a common goal.
• We are each responsible for customer service.
• We practice open communication at all levels of the company to foster individual, team and company growth.
• We actively participate in efforts to improve our many communities-internally and externally.
• We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.
• We encourage creativity, innovation, and the pursuit of excellence.

Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.

This job has expired.