Appeals and Grievance Resolution Specialist

2 weeks ago

Sunrise Manor, Nevada, United States Community Care Plan Full time

Position Overview:

This role within the Quality Department focuses on the investigation and resolution of member complaints, grievances, and appeals in accordance with regulatory standards. The position also involves the preparation and coordination of State Fair Hearing/IRO packets and participation in State Fair Hearings.

Key Responsibilities:

  1. Receive, investigate, resolve, track trends, and report all complaints, grievances, and appeals across various business lines.
  2. Maintain comprehensive logs for complaints, grievances, and appeals for all business sectors.
  3. Oversee the complete process of case development and resolution for complaints, grievances, and appeals, which includes:
  • Conducting thorough research and gathering necessary documentation.
  • Understanding and applying internal policies and procedures to inform decisions.
  • Interpreting relevant regulations.
  • Making critical decisions to resolve cases.
  • Managing all tasks within regulatory deadlines.
  • Finalizing and dispatching acknowledgment and resolution correspondence.
  1. Ensure the resolution of member complaints, grievances, and appeals concerning quality of care, medical necessity, plan benefits, and payments, in compliance with state and federal regulations and NCQA standards.
  2. Facilitate monthly and ad hoc grievance and appeals committee meetings.
  3. Communicate decisions regarding grievances and appeals to participants within the required regulatory timelines, ensuring adherence to strict deadlines for both urgent and non-urgent requests.
  4. Guarantee accurate and timely processing of appeals through internal appeals, independent external reviews, or Medicaid Fair Hearing processes.
  5. Analyze data related to complaints, grievances, and appeals, generate trend reports, and collaborate with various committees to identify improvement opportunities aimed at enhancing member satisfaction.
  6. Monitor delegated partners' complaint, grievance, and appeal activities to ensure compliance.
  7. Collaborate with other departments to identify issues and develop action plans to address deficiencies.
  8. Prepare detailed reports for submission to relevant agencies on a monthly and quarterly basis.
  9. Present data and recommendations to internal committees and workgroups, such as the Quality Improvement Committee.
  10. Maintain an up-to-date understanding of contract requirements, accreditation standards, and applicable laws and regulations.
  11. Develop, revise, and uphold grievance and appeal policies and procedures to accommodate new business lines and reflect changes in contracts, accreditation standards, and regulations.
  12. Design and implement training programs to facilitate quicker resolutions of member issues and enhance understanding of member appeal rights.
  13. Assist internal stakeholders during federal, state, and internal audits of grievance and appeals processes, including data validation activities, and lead presentations of appeals and grievance documentation during audits.
  14. Perform additional duties as required.

This job description does not imply that these are the only duties performed by the employee in this position. Employees may be required to perform other job-related tasks as assigned by their supervisor or management.

Skills and Competencies:

  • Problem-solving: Effectively identifies and resolves issues promptly; gathers and analyzes information skillfully; develops alternative solutions; collaborates well in group problem-solving situations; applies reason even in emotionally charged circumstances.
  • Verbal Communication: Clearly and persuasively communicates in various situations; listens actively and seeks clarification; responds effectively to inquiries; demonstrates strong group presentation skills; participates in meetings.
  • Written Communication: Produces clear and informative written content; edits for spelling and grammar; adapts writing style to meet diverse needs; presents numerical data effectively; comprehends and interprets written information.
  • Flexibility: Demonstrates a willingness to learn and adapt to changes in regulations and task priorities.

Work Schedule:

Community Care Plan currently operates on a hybrid work schedule, allowing staff to work from home three days a week while reporting to the office two days a week. The company reserves the right to modify work schedules based on operational needs.

Physical Requirements:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform these functions. The employee is regularly required to sit, use hands, reach with hands and arms, and communicate verbally. The employee frequently stands, walks, and sits. Occasionally, the employee may stoop, kneel, crouch, or crawl, and may lift and/or move up to 15 pounds.

Work Environment:

The work environment characteristics described here are representative of those an employee may encounter while performing the essential functions of the job. The environment includes both office and travel settings. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions. The noise level in the work environment is typically moderate.

Community Care Plan is an equal opportunity employer, committed to fostering a diverse and inclusive workplace. We recruit, employ, train, compensate, and promote individuals without regard to age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique.

Qualifications:

  • High school diploma or General Education degree (GED) required; Associate's degree preferred; two to four years of relevant experience and/or training; or an equivalent combination of education and experience.
  • 1 to 2 years of experience in healthcare.
  • Familiarity with HIPAA regulations, Medicaid, and CHIP.
  • Proficient in Microsoft Office applications, including Word and Excel.

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