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Member Grievance and Appeal Specialist

2 months ago

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

Position Overview:

The Grievances and Appeals Coordinator plays a crucial role within the Quality Department, tasked with investigating and resolving member complaints, grievances, and appeals in accordance with regulatory standards. This 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, and track all complaints, grievances, and appeals across various business lines.
  2. Maintain comprehensive logs for complaints, grievances, and appeals.
  3. Oversee the complete process of case development and resolution, which includes:
  • Conducting thorough research and gathering necessary documentation.
  • Applying internal policies and procedures to inform decision-making.
  • Interpreting relevant regulations.
  • Making critical decisions to resolve cases.
  • Ensuring all tasks are completed within regulatory timeframes.
  • Finalizing and dispatching acknowledgment and resolution correspondence.
  1. Manage the resolution of member complaints and appeals concerning quality of care, medical necessity, plan benefits, and payment issues, ensuring compliance with state and federal regulations as well as NCQA standards.
  2. Facilitate monthly and on-demand grievance and appeals committee meetings.
  3. Communicate decisions regarding grievances and appeals to participants, adhering to strict regulatory timelines for both urgent and non-urgent requests.
  4. Ensure accurate and timely processing of appeals through internal and external review processes.
  5. Analyze data related to complaints and grievances, generating trend reports and collaborating with committees to identify improvement opportunities for enhanced member satisfaction.
  6. Monitor compliance of delegated partners in care regarding complaints and grievances.
  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. Provide data and recommendations to internal committees and workgroups, such as the Quality Improvement Committee.
  10. Maintain a thorough understanding of contract requirements, accreditation standards, and applicable laws and regulations.
  11. Develop and update grievance and appeal policies and procedures to align with new business lines and changes in regulations.
  12. Design and implement training programs to enhance understanding of member appeal rights and expedite issue resolution.
  13. Assist in federal, state, and internal audits of grievance and appeals processes, presenting documentation as needed.
  14. Perform additional duties as required.

This job description does not encompass all duties performed by the employee in this role. Employees may be required to undertake other job-related tasks as assigned by management.

Skills and Competencies:

  • Problem Solving: Effectively identifies and resolves issues; analyzes information skillfully; develops alternative solutions; collaborates well in group settings; maintains composure in emotional situations.
  • Verbal Communication: Communicates clearly and persuasively; listens actively and seeks clarification; responds effectively to inquiries; demonstrates strong presentation skills.
  • Written Communication: Produces clear and informative written content; edits for accuracy; adapts writing style to suit different needs; effectively presents numerical data.
  • Adaptability: Shows flexibility and a willingness to learn and adjust to changing regulations and 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:

Employees must be able to meet the physical demands necessary to perform essential job functions. Reasonable accommodations may be made for individuals with disabilities. Regular activities include sitting, using hands, reaching, and communicating. Employees may occasionally need to stand, walk, stoop, kneel, or lift up to 15 pounds.

Work Environment:

The work environment includes both office and travel components. Reasonable accommodations may be made for individuals with disabilities. The typical noise level is moderate.

Community Care Plan is an equal opportunity employer, committed to diversity, equity, and inclusion in the workplace.

Qualifications:

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