HP Grievance & Appeals Coordinator
Department Name:
Banner Staffing Services-AZ Work Shift:
Day Job Category:
General Operations
The future is full of possibilities. At Banner Plans & Networks, we’re changing the industry to reduce healthcare costs while keeping members in optimal health. If you’re ready to change lives, we want to hear from you.
Banner Plans & Networks (BPN) is a nationally recognized healthcare leader that integrates Medicare and private health plans. Our main goal is to reduce healthcare costs while keeping our members in optimal health. BPN is known for its innovative, collaborative, and team-oriented approach to healthcare. We offer diverse career opportunities, from entry-level to leadership positions, and extend our innovation to employment settings by including remote and hybrid opportunities.
As a Health Plans Grievance and Appeals Coordinato r, you will play a critical role within Banner Plans & Networks, ensuring the timely intake, review, investigation, and resolution of grievances, appeals, and provider disputes. This is a high-volume, fast-paced position that requires prior knowledge of grievance and appeals processes . In this role, you will research complex claim and service issues, determine appropriate levels of review, coordinate with internal teams and providers, document findings, and prepare professional correspondence including acknowledgment and resolution letters. Success in this position requires exceptional attention to detail, strong written communication skills, sound judgment, and the ability to efficiently navigate multiple systems while delivering accurate, compliant, and timely resolutions that support both provider satisfaction and business objectives.
In this role, you will primarily be working in a remote setting. CANDIDATES MUST RESIDE IN THE STATE OF ARIZONA TO BE CONSISDERED . Work shifts will be 8:00 a.m.-5:00 p.m. Monday-Friday. If this role sounds like the one for you, Apply Today!
Registry/Per Diem positions do not have guaranteed hours and no medical benefits package is offered. Completion of post-offer Occupational Health physical assessment, drug screen and background check (includes employment, criminal and education) is required.
POSITION SUMMARY
This position handles member and provider grievances, appeals and claim disputes. This position will act as a key advocate and contact for HP members with general health care and accessibility concerns and inquiries on the various levels of the grievance and appeals process.
CORE FUNCTIONS
1. Determines which claim disputes meet acceptable claim dispute criteria, specifically screening for Untimely claims and Resubmissions; maintains a log, categorizes and tracks all received documents, notices, returned receipts; decides and responds to those appeals and claim disputes not meeting criteria with appropriate correspondence and routing. Assists in resolving member questions and concerns regarding the health care system in an effort to prevent the need for members to file formal grievances or appeals.
2. Enters all accepted appeals and claim disputes and its corresponding information into the CRM; creates and maintains case files, including appropriate review sheets for Medical Review and/or Claim Review according to policy, AHCCCS, HCG, and CMS regulations; updates CRM for ongoing cases with responses from reviewers. Assesses individual cases and documents in various CRM programs for pertinent information for referral and/or transmission to co-workers.
3. Ensures all appeals and claim disputes are acknowledged, by official correspondence, within AHCCCS, HCG, and CMS contractual timelines; protects the confidentiality of member information and other information. Facilitates, communicates and accepts input regarding member and provider appeal information from appropriate individuals that would include employees, providers, Medical Director, Plan Administrator, RNs, Risk Management, attorneys, AHCCCS, HCG, CMS and others.
4. Responds to all inco