Job Information
Independent Health Contractual Reviewer - Senior in Buffalo, New York
FIND YOUR FUTURE
We're excited about the potential people bring to our organization. You can grow your career here while enjoying first-class perks, benefits and commitment to diversity and inclusion.
Overview
The Contractual Reviewer-Senior will be responsible for providing an organized, timely and consistent review and investigation of provider and/or member complaints and/or appeals. The Contractual Reviewer-Senior will be required to rely on their ability to synthesize a great deal of information in the interest of effectively understanding the matter at hand to, in turn, determine the steps that need to be taken to resolve the issue. The individual will frequently be called upon to collaborate with multiple departments and associates to properly investigate appeals/complaints. The Contractual Reviewer-Senior will also be responsible for providing member education/outreach related to coverage determinations and member benefit contract information.
Qualifications
High school diploma or GED required. Associates degree preferred.
Three (3) years of experience in a member or provider focused position required. Experience with healthcare benefits, contracts, and medical terminology preferred.
Ability to understand and articulate complex issues, systems, process and/or concepts with minimal assistance from management required.
Ability to analyze problems systematically, organize information, identify underlying causes and generate solutions while recognizing the impact on stakeholders and the organization.
Excellent verbal, written and interpersonal communication skills required.
Ability to handle escalated calls and to deliver messages clearly and articulately regarding decisions.
Possess initiative, attention to detail, and solid, logical thinking capabilities.
Proven ability to manage multiple, time-sensitive priorities and adherence to all deadlines, while remaining organized in a fast paced, ever-changing environment.
Proven examples of displaying the IH values: Passionate, Caring, Respectful, Trustworthy, Collaborative and Accountable.
Essential Accountabilities
Research
Investigate and research all levels of complaints/appeals independently to determine the resolution of the complaint/appeal.
Frequent review of Independent Health policies, contracts, clinical documentation, claims systems, pharmacy formularies, procedures and department directives is required.
Collaboration with internal and external resources to resolve all levels of complaints/appeals.
Manage an individual workload assigned in respect to upcoming absences to adhere to regulatory timeframes.
Research, investigate, and make decisions based off research with respect to appeals and complaints in accordance with established guidelines, regulations, and member contracts.
Compliance
Solid understanding of the multiple requirements that require absolute compliance in terms of the timeframes for each activity in the handling of appeals/complaints.
Ensure verbal and written responses to complaints/grievances, appeals and investigations follow regulatory standards.
Provide member education/outreach related to coverage determinations and member benefit contract.
Identify appeal trends and process improvements where applicable.
Reporting/Accuracy in Documentation
Document all appeal/complaint activity thoroughly and accurately by creating a detailed summary of all findings.
Information gathered in appeal/complaint activity is relied upon for internal and external reporting, so careful attention to detail is a high priority.
Monitor daily reports to ensure accuracy and timeliness of complaints/grievances and appeals.
Assist in continuously developing systems, workflows, and coverage criteria to better meet the needs of the customer.
Coordination
Coordinate and collaborate with ancillary departments and peers within the contractual team in rendering consistent coverage determinations and claims payments in accordance with policy, regulations, and member benefit contract.
Demonstrate positive interrelationships and service excellence in performance of duties by meeting or exceeding the expectations of internal and external service groups.
Coordinate with external agencies to prepare case files when needed for external appeals.
Departmental Support
Assist in meeting department goals and objectives and identify process improvements to continuously improve member/provider satisfaction.
Attend assigned meetings as department representative and report to team members when necessary.
Immigration or work visa sponsorship will not be provided for this position
Hiring Compensation Range: $22 - $25 hourly
Compensation may vary based on factors including but not limited to skills, education, location and experience.
In addition to base compensation, associates may be eligible for a scorecard incentive, full range of benefits and generous paid time off. The base salary range is subject to change and may be modified in the future.
As an Equal Opportunity / Affirmative Action Employer, Independent Health and its affiliates will not discriminate in its employment practices due to an applicant’s race, color, creed, religion, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender identity or expression, transgender status, age, national origin, marital status, citizenship and immigration status, physical and mental disability, criminal record, genetic information, predisposition or carrier status, status with respect to receiving public assistance, domestic violence victim status, a disabled, special, recently separated, active duty wartime, campaign badge, Armed Forces service medal veteran, or any other characteristics protected under applicable law. Click here (http://www.independenthealth.com/about/careers/additional-eeo-aap-information) for additional EEO/AAP or Reasonable Accommodation information.
Current Associates must apply internally via the Job Hub app.
The Independent Health Family of Companies, headquartered in Buffalo, NY, serves nearly 400,000 members and provides innovative health care products and benefits designed to engage consumers in their health and well-being. Established in 1980, our comprehensive portfolio includes Pharmacy Benefit Dimensions, Reliance Rx, Nova Healthcare Administrators, Care for You and the Independent Health Foundation.
Our culture sets us apart. Our core values drive who we are and the work we do. As a member of our family, you’re part of something special, in your work and in the community.
We understand and appreciate that everyone has unique experiences, perspectives and identities which is why we pledge to create a safe space where all people and ideas are welcomed. We are here to continue learning and to generate important dialog.
We are committed to doing what matters most - reaching out, working together, and caring for our community. A healthy community benefits everyone who lives in it. You too can be part of making difference in the lives of others, together we achieve so much more. Please click here (http://www.independenthealth.com/about/community-report) to view our Community Reports.
Apply today and join us on the journey to a happier, healthier, and more inclusive community.
We are committed to providing reasonable accommodations for qualified individuals with disabilities and disabled veterans. We are a drug-free workplace. An applicant for employment in need of an accommodation to participate in the application and recruitment process should contact Human Resources at: accommodations@independenthealth.com or Human Resources, 511 Farber Lakes Drive, Williamsville, NY 14221.
Please note, we do not accept unsolicited resumes. We do not accept resumes from headhunters, placement agencies, or other suppliers that have not signed a formal agreement with us.
