Senior Complaint and Appeals Analyst-PCHP (Dallas, TX, US) - Parkland Hospitals

Interested in a career with both meaning and growth? Whether your abilities are in direct patient care or one of the many other areas of healthcare administration and support, everyone at Parkland works together to fulfill our mission: the health and well-being of individuals and communities entrusted to our care. By joining Parkland, you become part of a diverse healthcare legacy that’s served our community for more than 125 years. Put your skills to work with us, seek opportunities to learn and join a talented team where patient care is more than a job. It’s our passion.

Primary Purpose

Parkland Community Health Plan’s (PCHP’s) Senior Complaint and Appeals Analyst is responsible for intake, investigation, distribution, and resolution of complaints and appeals for Medicaid including STAR, CHIP, and CHIP Perinate. Cooperates with multiple business units to obtain all information needed to assure final resolution and response. Ensures timely, customer focused acknowledgment of all complaints and appeals. Identifies and reports trends and emerging issues and recommends solutions.

Minimum Specifications

Education

High School Diploma

Experience

• Five years of experience in managed care products and benefits.
• Three years of experience in medical claims systems, medical management, managed care organization compliance and regulatory requirements.
• Experience in provider relations, customer service and audit experience are preferred.
• Experience in research and analysis of claim processing is preferred.

Equivalent Education and/or Experience

• May have an equivalent combination of education and experience to substitute for both the education and the experience requirements.

Skills or Special Abilities

• Bilingual in English and Spanish is preferred.
• Thorough knowledge of member and provider appeals, complaints policies.
• Maintains composure and compassion when juggling a high volume of tasks and deadlines.
• Ability to form collaborative working relationships.
• Strong analytical skills focusing on accuracy and attention to detail.
• Outstanding interpersonal communication skills, both verbal and written.
• Ability to multi-task and use multiple computer applications at one time.
• Proficient in Microsoft applications including Word, Excel, and Outlook.
• Knowledge of NCQA accreditation requirements is preferred.
• Experience with QNXT is highly preferred.

Responsibilities

• Collaborates with appropriate subject matter experts within another business units to effectively identify appeals and complaints in a timely and appropriate manner. Coordinates all components of appeals, complaints including final communication to member and provider for final resolution and closure.
• Responsible for reviewing, identifying, distributing, and documenting all incoming State (HHSC/TDI) e-mail, and fax complaints as well as all other complaints and appeals.
• Assists the Member Advocate in creating and maintaining an audit mechanism to measure the quality of work for both internal and external complaints and appeals work processes.
• Researches PCHP benefits and processes to determine accuracy and appropriateness of benefit and administrative denial or reduction.
• Researches claim processing logic to verify accuracy of claim payment, member eligibility data, billing and payment status, as part of the appeal and complaint process.
• Serves as a technical resource to colleagues regarding appeals, complaints issues, and similar situations requiring a higher level of expertise.
• Identifies trends and emerging issues regarding appropriate release and/or utilization of e-mail or fax information. Reports and gives input on potential solutions.
• Responsible for monitoring and resolving OnVida communication system tasks.
• Other duties as assigned.

Job Accountabilities

1. Identifies ways to improve work processes and improve customer satisfaction. Makes recommendations to supervisor, implements, and monitors results as appropriate in support of the overall goals of PCHP.
2. Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices.
3. Maintains knowledge of applicable rules, regulations, policies, laws, and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and customer requirements. Seeks advice and guidance as needed to ensure proper understanding.

Parkland Health and Hospital System prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status.As part of our commitment to our patients and employees’ wellness, Parkland Health is a tobacco and smoke-free campus.