Solutions Unit Coordinator - RN or LPN

General Summary

The Solutions Unit Coordinator will be responsible for managing all reconsiderations, appeals, grievances, provider inquiries and member inquiries, claims inquiries and member inquires in regard to appeals and grievances. The Solutions Unit Specialist is responsible for verbal and written communication internally and externally, completeness and accuracy of files and systems, timelines of processing inquiries, meeting regulatory standards, and for case preparation for Solutions Unit committee meetings.

 Essential Duties and ResponsibilitiesResearches grievance, appeals, and inquiries received for all lines of business, including contacting providers and/or members, reviewing claims, authorizations, system notes, and exploring all avenues to obtain information pertaining to the caseAssures that materials within each file are accurate, have timely entry, and comply with regulatory standards.Prepares cases for presentation to committee meetings. Present cases at meetings as needed.Utilizes appropriate letters to providers and members acknowledging receipt of appeal, grievance or inquiry, committee and/or review decisions, and appeal rights.Assists in preparing reports for regulatory agencies, internal and external committees and others as requested.Assists in accurately tracking grievances, appeals, reconsiderations, and inquiries using system databases. Assists in tracking and reporting data as needed.Communicates with members, providers, and internal staff, providing answers to questions, assisting with reconsiderations, grievances, appeals and inquiries.Assists team members in completing daily operations activities.Coordinates all reconsiderations, appeals, and grievances with external vendors.Provides training and orientation to team members.Maintains strong working relations with internal and external customers.Assists Solutions Unit Manager in tasks as assigned.Maintains confidentiality on all inquiries, reconsiderations, appeals, and grievances.Performs other duties as assigned.

 

 

 

 

 

 

 

 

 

 

 Job Qualifications

Required Education and Experience:LPN or RN preferred or college degree in related field

Preferred Education and Experience:1-2 years experience in managed care environment working with appeals, grievances, and provider and member inquiries preferred.Knowledge of claims and coding preferred. 

 Additional SkillsDetail orientedAbility to use computer applications including databases (Access), spreadsheets (Excel), and Word Processing.Possesses strong written and verbal communication skills.Works well in a team environment.Goal oriented.Ability to analyze data to identify significant trends and opportunities for improvement.Ability to handle multiple tasks, set priorities, and develop action itemsHighly self-motivated, dependableKnowledge of regulatory requirements with emphasis on MedicareKnowledge of managed care, claims, eligibility, regulatory requirements, and inquiry processes. 

 Working Conditions/Physical Demands

The physical demand described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

 

While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, feel, talk, or hear. The vision requirements include: close vision, distant vision, peripheral vision, depth perception, and the ability to adjust focus.

HealthSpring offers a competitive salary and full range of benefits

For more information and to apply 

visit www.myhealthspring.com and complete an application.

All interested candidates must complete an on line application

Select Department:  Health Services

Select Position: Solutions Unit Coordinator

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No phone call accepted

HealthSpring USA, LLC is an EEO/AA employer.