9901 - Signature Advantage

9901 – Signature Advantage

Louisville, KY, US, 40299


For additional information, please contact:
Hillary Bayens, Director of Talent Acquisition


Signature HealthCARE is a family-based healthcare company that offers integrated services in 8 states across the continuum of care: skilled nursing, rehabilitation, assisted living, memory care, cognitive care, and telemedicine.

Signature Advantage, a subsidiary of Signature Healthcare, is an Institutional Special Needs Plans (I-SNP) which is a Medicare Advantage Plan. As an I-SNP, we provide a Medicare Advantage plan for people who are eligible for Medicare and who reside in our partner nursing facilities.

Our Sacred Seven Values of Heroic, Compassion, Teamwork, Respect, Integrity, Patience and Positivity make this an incredible place to serve and make a difference in the lives of our patients, residents, Stakeholders and communities!

How you will make a difference

* Responsible for receiving, investigating, and resolving Medicare Advantage (MA) member grievances and appeals, as well as appeals from non-participating providers, in accordance with company policy and the related regulatory requirements as set forth by the Centers for Medicare and Medicaid Services (CMS).

How you will spend your time

* Meet the physical and sensory requirements stated below and be able to work in the described environment.

Appeals Grievances:

* Perform comprehensive research on claims and analyze and resolve verbal and written claims and authorization appeals from providers and members.
* Pursue investigation and effectively communicate resolution of formal grievances to members.
* Gather, analyze, and report verbal and written member and provider complaints, grievances and appeals.
* Prepare response letters for member and provider complaints, grievances and appeals.
* Maintain files on individual appeals and grievances.
* May coordinate the Grievance and Appeals Committee.
* Support the pay-for-performance programs, including data entry, tracking, organizing, and researching information.
* Manage large volumes of documents and inventory including copying, faxing and scanning incoming mail.
* Participates in audits, including document preparation and participation in on-site or remote audits, as a subject matter expert.
* Prepare and submit documents to the IRE timely and accurately.
* Manage inventory volumes and turn around times with CMS required timeframes.
* Monitor appeals and grievances and provide senior management with monthly reporting on trends.
* Develops and updates policies and procedures annually and as needed or requested.
* Research claims appeals and grievances using support systems to determine appeal and grievance outcomes.
* Requests and reviews medical records, notes, and/or detailed bills as appropriate; formulates conclusions per protocol and other business partners to determine response; assures timeliness and appropriateness of responses per state and federal guidelines.
* Responsible for meeting production standards set by the department.
* Apply contract language, benefits, and review of covered services.
* Responsible for contacting the member/provider through written and verbal communication.
* Prepares appeal summaries, correspondence, and document findings. Include information on trends if requested.
* Composes all correspondence and appeal and or grievances information concisely and accurately, in accordance with regulatory requirements.
* Research claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment error.

Utilization Management Intake:

* Provide fax support, data entry, and routing of cases to the appropriate Utilization Management staff member.
* Enters data into authorization system for admissions, outpatient procedures, therapies, home health, and DME.
* Adheres to state and federal regulations.
* Promptly makes recommendations to ensure compliance with rules, regulations, policies and procedures.
* Promptly records authorization request information while meeting quality audit thresholds.
* Accurately verifies member eligibility and provider participation prior to routing case to Utilization Management Nurse, noting any discrepancies/problems in notes received from provider.
* Chooses appropriate ICD-10-CM, Rev Codes and /or CPT-4 procedure code at time intake is completed.
* Maintains a current knowledge base with regards to rules, regulations, policies, and procedures relating to precertification and concurrent review.
* Differentiates between routine and significantly sensitive matters or those issues which require prompt attention or escalation.
* Addresses requests promptly and courteously, honors commitments and displays persistence obtaining necessary information to address issues and problems.
* Perform other duties and projects as assigned.
* Other special projects and duties, as assigned.

The qualifications you will need

* High School Diploma required; Associate’s degree preferred.
* Knowledge of medical terminology, and CPT and ICD-10 codes preferred.
* One (1) to three (3) years of experience as an Intake Coordinator or comparable experience preferred.
* Two (2) years of experience in processing appeals and grievances in a MA environment with experience in negotiating resolutions and outcomes.
* Working knowledge of the MA regulatory requirements for processing Grievances and related sub-processes (i.e. QOC grievances); and Appeals and related processes (i.e. utilization management).
* Mandatory Overtime may include weekend days and holidays, based on business needs.
* Effective verbal and written English communication skills.
* Demonstrated intermediate to advanced skills in Microsoft Word, Excel, Power Point and Outlook, Internet and Intranet navigation.
* Highest level of professionalism with the ability to maintain confidentiality.
* Ability to communicate at all levels of organization and work well within a team environment in support of company objectives.
* Customer service oriented with the ability to work well under pressure.
* Strong attention to detail and accuracy, excellent organizational skills with ability to prioritize, coordinate and simultaneously maintain multiple projects with high level of quality and productivity.
* Strong analytical and problem solving skills.
* Ability to work with minimal supervision, take initiative and make independent decisions.
* Ability to deal with new tasks without the benefit of written procedures.
* Approachable, flexible and adaptable to change.
* Function independently, and have flexibility, personal integrity, and the ability to work effectively with stakeholders and vendors.: