Curana Health is a provider of value-based primary care services for the senior living industry, including skilled nursing facilities, assisted & independent living communities, Memory Care units, and affordable senior housing sites. Our 1,000+ clinicians serve more than 1,500 senior living community partners across 33 states, and Curana participates in various innovative CMS programs (including owned-and-operated Accountable Care Organizations and Medicare Advantage plans). With rapid year-over-year growth since our founding in 2021, Curana is setting a new standard in innovative care delivery for seniors with high-risk, complex clinical needs, many of whom have been historically underserved by the health care system. Our mission: To radically improve the health, happiness and dignity of senior living residents.

Primary Responsibilities

• Investigate and process member and provider appeals and grievances in a professional, timely manner, adhering to contractual time limits.
• Have a clear understanding of the differences in medical necessity appeals and claim appeals
• Works appeal and grievance cases which includes receiving, logging, tracking, monitoring, documenting, supporting documentation requests.
• Responds to member and provider appeals with minimal direction
• Prepares all appeals and grievances written documentation which include appeal and grievance outcome letters, appeal acknowledgement letters, and correspondences to next level of appeals
• Documents all appeals and grievances in an accurate and timely manner per policy, related follow-up activities and final outcomes in designated systems while concurrently maintaining secure, comprehensive, and clearly defined files.
• Generates reports with trend analysis and recommendations for quality improvement to Manager, as required
• Communicates detailed risk management issues to the Manager within the specified timeframe
• Read and comprehend appeal and grievance correspondences and reach out to appellant and or griever to obtain additional information as needed
• Works closely with member advocates to gain resolution for grievances
• Consults with internal departments such as Utilization Management, Claims, Provider Network and Legal, as well as company senior management to assure appeal and complaint decisions meet all guidelines and result in customer satisfaction when possible
• Consults with Management and external vendors to resolve high profile, complex appeals and/or complaints.
• Other duties as assigned

Minimum Qualifications/Requirements

• Minimum of High school graduation or GED required.
• Working knowledge of Medicare Advantage
• Experience in Medicare Advantage health insurance including customer service
• Exceptional interpersonal and problem-solving skills
• Positive and approachable demeanor
• Strong analytical and conflict resolutions skills as well as persuasion skills.
• Proficient in MS Office applications (Word and Excel)
• Ability to prioritize, work under pressure, while maintaining organization
• Understanding of operational process flow analysis and process improvement methods
• Experience working with firm deadlines with the ability to interpret and apply regulations.

Preferred Qualifications/Requirements

• Strong working knowledge of medical claims adjudication, medical billing, terminology, insurance, or health services preferred
• Familiarity with Medicare benefits preferred
• Understanding of the long-term care and provider-sponsored plans industries
• Ability and willingness to learn new software applications and adapt to change

Curana Health is dedicated to the principles of Equal Employment Opportunity. We affirm, in policy and practice, our commitment to diversity. We do not discriminate on the basis of actual or perceived race, color, creed, religion, national origin, ancestry, citizenship status, age, sex or gender (including pregnancy, childbirth and related medical conditions), gender identity or gender expression (including transgender status), sexual orientation, marital status, military service and veteran status, physical or mental disability, protected medical condition as defined by applicable or state law, genetic information, or any other characteristic protected by applicable federal, state and local laws and ordinances.

The EEO policy applies to all personnel matters as outlined in our company policy including recruitment, hiring, transfers, and general treatment during employment.