About Us
Here at Baylor Scott & White Health we promote the well-being of all individuals, families, and communities. Baylor Scott and White is the largest not-for-profit healthcare system in Texas that empowers you to live well.
Our Core Values are:
- We serve faithfully by doing what's right with a joyful heart.
- We never settle by constantly striving for better.
- We are in it together by supporting one another and those we serve.
- We make an impact by taking initiative and delivering exceptional experience.
Benefits
Our benefits are designed to help you live well no matter where you are on your journey. For full details on coverage and eligibility, visit the Baylor Scott & White Benefits Hub to explore our offerings, which may include:
- Eligibility on day 1 for all benefits
- Dollar-for-dollar 401(k) match, up to 5%
- Debt-free tuition assistance, offering access to many no-cost and low-cost degrees, certificates and more
- Immediate access to time off benefits
At Baylor Scott & White Health, your well-being is our top priority.
Note: Benefits may vary based on position type and/or level
Job Summary
Hybrid position - limited time working onsite
The Appeals and Grievance Specialist reviews member and provider complaints, appeals, and grievance cases for all business lines. Responsibilities include timely classification and resolution of cases. They also review, research, and coordinate complaints, grievances, appeals, and reconsiderations following statutory and federal guidelines.
Essential Functions of the Role
- Maintains data entry requirements for all complaints, appeals and grievances.
- Builds case files for each complaint, appeal and grievance, and ensures compliance with organizational and regulatory guidelines.
- Investigates concerns and disputes for all lines of business. Contacts members and providers to gather information and communicate case outcomes. Consults with health care providers, vendors, legal representatives, medical staff, and administration. Accurately documents all communication with involved parties. Reviews details submitted by members and providers. Verifies classifications and enters information into the data management system.
- Maintains case assignment worklist assuring cases are on track and closed within the regulatory turnaround time.
- Coordinates activities for all expedited and external case reviews, and prepares final case submissions.
- Refers clinical appeal cases to Medical Nurse Auditors or Pharmacy Technicians for handling where required.
- Ensure case closure correspondence follows regulatory and statutory requirements and responds to instructions from external review entities.
- Chairs and coordinates participation at appeal panel hearings. Coordinates with panel members and provides information before the hearing. Assures scheduling and physician follow-up to ensure attendance, as appropriate.
Key Success Factors
- Bachelor's degree in Healthcare, Administration, or related field preferred.
- Must have exceptional organizational, rational reasoning, critical, and problem-solving skills. Attention to detail is necessary for complex environments.
- Advanced oral and written communication ability required.
- Proficiency in Microsoft Office and Access.
- Ability to appropriately identify urgent situations and follow the appropriate protocol.
- Requires the ability to plan and manage multiple priorities within a fast-paced office environment.
- Must be able to work well autonomously and as a team member.
- Knowledge of basic medical terminology a plus.
Belonging Statement
We believe that all people should feel welcomed, valued and supported, and that our workforce should be reflective of the communities we serve.
QUALIFICATIONS
- EDUCATION - Bachelor's or 4 years of work experience above the minimum qualification
- MAJOR - Healthcare
- EXPERIENCE - 2 Years of Experience
