Bedford, United States
about 1 year ago
The Investigator is responsible for the analysis, investigation and resolution of internal and external (HHSC) complaints, contracted and non-contracted provider appeals, and Fair Hearings, as well as, for the timely and accurate resolution of call assigned cases and for the composition of the resolution letters for all case types.
Essential Duties and Responsibilities:
Works closely with staff at all levels of Cigna-HealthSpring to investigate, document, and resolve complex complaints. Conducts analysis, investigation and resolution of member appeals
Functions as the resource on contracted and non-contracted provider appeals.
Review, analysis and triage of all cases received via Call Tracker or in writing.
Prepares cases for second level appeals, QOC, fair hearing, or court preparation.
Responsible for determining the appropriate type of response to a requested appeal or complaint.
Must determine deadline dates on all cases and ensure they are met or exceeded.
Prepares all correspondence to gather and investigate a case.
Prepares a history of the investigation for each case.
Obtains clinical input as needed to resolve cases requiring medical input.
Refers cases to other departments to gather information to complete the investigation.
Independently makes decisions about the resolution of their assigned cases.
Documents the decision in a resolution letter to the appellant or grievant.
Ensures that overturns that require claims payment are processed with proof of payment placed in the file.
Maintains tracking and monitoring information on a database and software used in the department.
Provides tracking and trending reports to departmental leadership on the root causes of appeals and complaints and the high volume appellants.
Prepares cases for external review.
Responds to Expedited and Provider Claim appeals.
Keeps current with all requirements of STAR+PLUS plan appeals and complaints. Provides training to peers as necessary