Under the direction of the Revenue Cycle Manager, the Appeals and Grievances Coordinator will research, evaluate, and respond in a timely manner to appeals and grievances related to claims or prior authorizations. The coordinator will interpret and apply regulatory language and will prepare professional responses that are cohesive, logical, and that precisely address denial concerns. The coordinator will help to optimize net reimbursement from governmental funded carriers, commercial carriers, and workers compensation entities by ensuring services rendered are compensated. The coordinator will interface across clinical and administrative teams within FHW, and will be the primary contact for patients undergoing an appeal or grievance. The coordinator will investigate and respond to workers compensation denials to help optimize patient benefits. This person will investigate industry best practices to design innovative approaches to optimize appeal and grievance processes, and will share knowledge to help minimize their occurrence. This position is dynamic, and will require ongoing education and research to stay current with regulatory changes that affect the revenue stream.

You belong here! At Family Health West, you’re more than an employee, you’re family.

When you enter our facility, you know it’s Family Health West because, well, the color speaks for itself. You’ll be part of a team that strives to bring color to care in a vibrant environment by creating fun, effective treatment programs helping to empower and inspire our patients while providing the tools and care they need to achieve their wellness goals.

When we say you’ll do what you love, we mean it! Welcomed by open arms and warm smiles, you’ll join a team that encourages professional growth. We are sure to put on our listening ears when you share new ideas and approaches to care because that’s what got us to the top! You’ll wear your badge proudly, knowing that you contribute each day, to providing care that is unmatched, in western Colorado.

So, what are you waiting for?! Fill out the application now, and when you hit send do a little happy dance knowing that you just made our day. If it still sounds too good to be true, come see for yourself. Call us to schedule a tour and meet your new best friends!

About Family Health West

Our roots go deep -- founded by the community in 1946, it’s no wonder our hospital feels like coming home. We were built from the ground up with the hands of our own community, a labor of dedication and hope by our people, for our people, for the future.

At Family Health West we go beyond what corporate hospitals deliver, we’ve created a culture of prosperity where warmth, passion, and care flourishes. As we focus on continually improving outcomes for patients, our network of healthcare providers includes a 25-bed critical access hospital, one of the largest rehab providers in western Colorado, outpatient surgical services, specialty clinics, emergency services, skilled nursing, and assisted living facilities.

Nestled at the base of the Colorado National Monument, Family Health West has an outdoor paradise at your back door. The community culture is fitting for outdoor lovers, bikers, hikers, or those just simply soaking in the panoramic views.

ESSENTIAL FUNCTIONS:

• Research and document occurrences of denial and grievance concerns.
• Reliable and punctual attendance is essential; expected to be at job as scheduled each scheduled day.
• Communicate necessary information to others as appropriate.
• Investigate claim denial reasons, and work with carrier partners to respond according to complexity to preserve resources when possible.
• Manage caseload to ensure prompt replies, adherence to deadlines, and follow through to completion.
• Interact with clinicians to ensure responses are clinically sound, and that physicians agree with responses submitted on their behalf.
• Catalog and maintain detailed grievance and appeal case files and ensure they are audit ready at all times.
• Outreach to providers and carrier partners to resolve member complaints and grievances.
• Develop and maintain SOPs and protocols for appeal and grievance procedures.
• Adhere to internal grievance and appeals processes and regulatory requirements.
• Maintain electronic and/or hard copy regulatory binders for Medicare, Medicaid, commercial payers, and Workers Compensation.
• Gather data and statistics related to appeals relevant to legislative, lobbying, or regulatory opportunities.
• Track education and training to demonstrate competencies, and to help encourage education among teams.
• Proofing and drafting of medical or administrative correspondence as requested by outside teams.
• Team orientation and ability to work effectively across functional areas of the organization.
• Ability to work independently while adhering to organizational protocols and SOPs.
• Goal oriented with the ability to multitask, meet deadlines and maintain department quality standards.
• Strong computer skills including Excel and Microsoft Word.
• Ability to cope well with ambiguity and stressful situations.
• Willingness to take on new and complex tasks.
• Thrive in a fast-paced and collaborative team environment.
• Conduct problem identification, problem solving and process improvement recommendations.
• Ensure all cases are handled and resolved in compliance with timeline requirements and the highest standards for accuracy.
• Assist with generating appeal and denial reports as requested.
• Provide administrative support, including generating and mailing correspondence, forms or other notices.
• Identify barriers to customer satisfaction and timely case response and recommend actions to address operational challenges.
• Manage large volumes of documents including copying, faxing and scanning.
• Actively participate in all departmental meetings, training sessions, and other activities.
• Other duties as assigned.

EDUCATION:

Opening Info: Position open until filled.

WAGE RANGE: The wage for this position starts at $22.05 and goes up based on experience.

Immunizations required for employment, including COVID-19.

FHW offers a full benefits package including:

FOR ALL EMPLOYEES:

Employee Assistance Program

403 (B) with 4% match from FHW and zero day vesting schedule

FOR FULL TIME EMPLOYEES WORKING AT LEAST 30 HOURS A WEEK

Medical Plan Options:

PPO plan with copay/coinsurance and lower deductible

1. High Deductible Health Plan with the option for a Health Savings Account.

• Telemedicine includes in both plan options.

Dental

Vision

Life Insurance/ Accidental Death and Dismemberment Insurance

Disability Insurance with a Short and Long Term Option.

Critical Illness and Accident Plans

Cafeteria Options: Health Reimbursement/ Flex Savings / Dependent Childcare

A host of other options to include: Pet Insurance, Identity Protection, Travel protection.

Experience

• Minimum of 3 years’ experience in a clinic or administrative/ support role. Working knowledge of eligibility verification, health plan benefit interpretation, prior authorization procedures, workers compensation, and claim submissions. Working knowledge of regulatory and legislative requirements for appeals Experience performing grievance and appeals processing. Working knowledge of global hospital regulations to include HIPAA.

Education

• Associates or better in Health Services Administration