Heidi Johnson

*Research and respond to customer appeals and grievances as well as complaints filed through the Office of the Commissioner of Insurance (OCI).

*Interpret contracts and company guidelines, policies and procedures, including Wisconsin State Statutes, CMS and Federal and State guidelines. Proactively identify issues and problems affecting quality and take ownership of resolution.

*Research each case thoroughly and prepare grievance packets for the Grievance and Appeal Committee members, including the grievant within defined due dates. Prepare draft responses to customer appeals and grievances, OCI complaints, IROs within the required time frame of each. Maintain accurate and complete complaint, grievance / appeal database and Sharepoint in a timely manner.

*Coordinate all follow up and subsequent action needed as a result of the case review (i.e., claims and / or authorization processing. Prepare and sent appropriate files to OCI/IROs via electronic portals.

*Assist management with implementing and updating P&Ps as required.

*Maintain physical and technical security and privacy of protected health information (PHI).

*Knowledge of claims processing and adjudication.

*Knowledge of prior authorization of services and the policies and procedures.

*Facilitator of the Grievance and Appeals Meetings via Zoom / Microsoft Teams including scheduling the meetings, requesting medical records.

*Work with the Legal personnel to ensure grievances and appeals processes are completed timely and accurately according to contract requirements and internal procedures. Respond to appeals received from Providers with regards to non payment of claims and preauthorization requests.

*Submit requests to internal staff for medical review.

*Train new employees on the Grievance and Appeal process

*Participate in the Code Coverage Committee which review new codes quarterly and determines if payable or not.