Grievance & Appeals Dispute Resolution Agent Specialist

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Administrative & Support
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EmblemHealth
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Respond to written Dispute Resolution Agent (DRA) appeals submitted by contracted facilities as applicable based on their contract.  Types of correspondence handled by the individual will include, but is not limited to; correspondence, HQSI and ESMSEF appeals.  The financial consequences of an error could be significant as missed timeframes requires the plan to cover the claim in question. Incumbent must have strong organizational skills with attention to detail.

Responsibilities:

  • Receive new appeals and compile appeal packets
  • Review new appeal receipts to confirm request is valid and to identify the contracted DRA agent.  If request is invalid, notify the facility in writing with the reasons why the request is not valid.
  • Prepare cases for the DRA, reviewing the previous appeal file and compiling all applicable documents to create an appeal packet.
  • Facilitate the investigation of DRA cases submitted by par facilities.
  • Submit appeal packet via UPS or DRA agent portal, as applicable.
  • Provide written email notification to the contacted facility, notifying them that the request has been submitted to the DRA.
  • Receive DRA decision, updating all applicable systems and notifying delegates as applicable
  • Monitor their email and the DRA agent portal for decisions
  • Review decision to confirm accuracy and append to the system
  • Document the decision in ESAWS and notify the Senior Medical Clerk (SMC) to update the care management system
  • For delegate cases, notify the applicable delegate of the decision via email.
  • If decision is overturned, the DRA specialist will reach out to claims to facilitate the effectuation of the decision.
  • Must ensure timeframes are met and files are completed per G&A operational policies and procedures.
  • Monitor daily and weekly pending reports and Esaws work list to ensure timely submission of files.
  • Classify and code ESaws inquiries appropriately, entering all actions taken in investigation for auditing and reporting purposes. 
  • Make necessary follow-up calls to the facility or reach out to the DRA agent via email for any additional information.
  • Liaisons with claims to ensure determinations are effectuated within stringent timeframes. 
  • Regular attendance is an essential function of the job.  Performs other duties as assigned or required.

Qualifications:

  • Associates’ degree preferred or equivalent relevant work experience required
  • Excellent organization skills
  • Ability to work under pressure and deliver accurate and timely results
  • Excellent verbal and written communication skills
  • Understanding of Health Insurance knowledge
  • Problem solving and analytical skills

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