CTM Coordinator, Appeals & Grievances

This is a fully remote position, open to applicants in United States.

📋 Description

• Daily monitoring of the CTM portal for new cases

• Acknowledge the receipt of CTM grievances and appeals

• Collect information from members, providers, internal departments, and delegated entities to find suitable resolutions

• Inform relevant parties and ensure internal processes are completed before regulatory deadlines

• Conduct both verbal and written outreach to members and providers, adhering to plan policy and CMS guidelines

• Execute impartial, accurate, timely, and thorough investigations of CTM cases, grievances, and appeals

• Record all actions taken to resolve cases in compliance with CMS regulatory timeframes and internal policies

• Track cases to closure, ensuring timely and comprehensive documentation meets CMS requirements

• Process CTM cases, grievances, and appeals according to CMS guidelines and plan policies

• Compose clear and compliant written responses to CMS within specified turnaround times

• Prepare objective, accurate, and comprehensive case histories for committee meetings and workgroups

• Generate monthly and quarterly reports

• Assist in compliance reporting and regulatory audits

• Identify trends in appeals, grievances, and complaints, as well as systemic issues, and seek opportunities to enhance member experience and lower complaint volume

• Offer suggestions that support strong CMS STAR performance

• Engage in the review and updates of CTM, grievance, and appeal policies and procedures

• Participate in CMS audit preparation and regulator meetings and interviews

• Meet or surpass internal and regulatory deadlines

• Perform additional duties as assigned

⛳️ Requirements

• Minimum of one year of experience in Member Services or a related field

• Over 2 years of experience with Medicare Advantage healthcare plans

• High school diploma or GED

• Excellent oral and written communication skills

• Capable of drafting correspondence for CMS

• Strong attention to detail with the ability to manage multiple deadline-driven cases concurrently

• Proficient in typing at least 40 words per minute and using a 10-key keypad by touch

• Ability to communicate positively, professionally, and effectively; demonstrate leadership; teach; and collaborate across departments

• Ability to establish and maintain constructive relationships with diverse members, management, employees, and vendors

• Proficient in reading and interpreting safety rules, operating and maintenance instructions, and procedure manuals; writing routine reports and correspondence; and effectively speaking before groups of customers or employees

• Capability to perform basic arithmetic using U.S. currency and measurements of weight, volume, and distance

• Ability to apply logic and reasoning to resolve problems efficiently and strategically

• Strong problem-solving, organizational, and time-management skills

• Preferred: Direct experience with CTM cases at a Medicare Advantage healthcare plan

• Preferred: Associate degree (A.A.)

• Preferred: Bilingual in English and Spanish

🏝️ Benefits

• Remote work options

• Opportunities for growth and innovation

• Equal Opportunity/Affirmative Action employment