Appeals-Grievance Coord I
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Samaritan Health Plans (SHP) provides health insurance options to Samaritan employees, community employers, and Medicare and Medicaid members. SHP operates a portfolio of health plan products under several different legal structures: InterCommunityHealth Plans, Inc. (IHN) is designated as a regional Coordinated Care Organization (CCO) for Medicaid beneficiaries; Samaritan Health Plans, Inc. offers Medicare Advantage, Commercial Large Group, and Commercial Large Group PPO and EPO plans; SHP is also the third-party administrator for Samaritan Health Services’ self-funded employee health benefit plan.
As part of an Integrated Delivery System, Samaritan Health Plans is strategically and operationally aligned with Samaritan Health Services’ mission of Building Healthier Communities Together.
This is a remote position in which we are able to employ in the following states: Arizona, Arkansas, Connecticut, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Carolina, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, or Wisconsin
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JOB SUMMARY/PURPOSE
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Responsible for grievance and appeals coordination and resolution for all Samaritan Health Plan (IHN, SAHP, Commercial, Choice) members who engage with the grievance process. Coordinates and resolves complaints and inquiries (included in “grievances”) from regulatory agencies, consumer rights organizations and legislators. Responsible for the documentation, monitoring and regulatory reporting obligations
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DEPARTMENT DESCRIPTION
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Samaritan Health Plans (SHP) operates a portfolio of health plan products under several different legal structures: InterCommunity Health Plans, Inc. (IHN) is designated as a regional Coordinated Care Organization (CCO) for Medicaid beneficiaries; Samaritan Health Plans, Inc. offers Medicare Advantage, Commercial Large Group, and Commercial Large Group PPO and EPO plans; SHP is also the third-party administrator for Samaritan Health Services’ self-funded employee health benefit plan. As part of an Integrated Delivery System, Samaritan Health Plans is strategically and operationally aligned with Samaritan Health Services’ mission of Building Healthier Communities Together.
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EXPERIENCE/EDUCATION/QUALIFICATIONS
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High school diploma or equivalent required. Bachelor’s degree in a related field preferred.
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Two (2) years health plans experience required. One (1) year experience in Appeals & Grievance preferred.
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KNOWLEDGE/SKILLS/ABILITIES
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Ability to apply critical thinking in resolving grievances and evaluating data to make effective recommendations for global problem solving. Ability to analyze trends and recommend improvements in procedures, materials, and products to prevent future member or other stakeholder concerns.
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Ability to act professionally and remain calm in stressful situations.
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Outstanding verbal and written communication skills. Ability to read, understand and apply complex procedures and concepts. Ability to present information in a clear and concise manner. Effective interpersonal skills while dealing with members, stakeholders, and coworkers. Ability to build strong relationships with stakeholders to achieve results.
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Strong organizational/project management skills and ability to manage administrative functions. Ability to use good judgment and act decisively at the right time. Ability to work and problem solve independently as well as an integral part of a team.
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Knowledge of and proven proficiency using personal computers including the use of Microsoft Office applications.
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In-depth knowledge of health insurance operations, Samaritan Health Plans (SHP) products, SHP procedures and legal and regulatory requirements. Ability to learn and use an insurance system. Knowledge of or ability to learn HIPAA requirements.
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PHYSICAL DEMANDS
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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
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