Senior G&A Specialist

Overview

Resolves grievances, appeals and external reviews for the multiple product lines of VNS Health ensuring that regulatory compliance, timeliness requirements and accuracy standards are met. Mentors Grievance & Appeals Specialists (GAS), Regulatory Specialists, and Senior Coordinators and assists with challenging cases. Performs second-level review on completed G&A cases where necessary to ensure quality and accuracy. Identifies and communicates areas for improvement in processes and training to G&A Management.

Supports training and orientation of new staff. Coordinates efficient functioning of day-to-day operations, from intake to completion of cases, according to defined processes and procedures. Creates and maintains accurate records documenting the actions and rationale for each grievance or appeal decision. Supports management as needed in creation of intra-and inter-Departmental reporting of Grievance & Appeals data. Develops correspondence communicating the outcome of grievances and appeals to enrollees and providers and supports RN reviewers in doing same.

Assists with collecting and reporting data. Identifies issues for escalation to Department management. Works under general supervision.

Grievance & Appeals experience required.

• Develops and maintains current knowledge of state/federal regulatory and contractual requirements related to all aspects of grievances and appeals for Medicare and Medicaid managed care organizations.
• Mentors Grievance and Appeals Specialists, Senior Coordinators, Regulatory Specialists and supports skill development as needed while maintaining a case load of grievances and appeals. Assists with day to day operational issues, provides support with questions, and supports with coverage as needed which includes but is not limited to intake, grievances, appeals, regulatory complaints, and the level 2 appeal process for all lines of business.
  
  Identifies and assists with challenging cases, and classes of cases with greater potential impact on Department compliance, STARS, and other Plan priorities. Assists GASs in identifying issues for escalation to Department management.
• Performs secondary review of GASs completed cases to ensure quality and accuracy. Recommends areas for GAS training and process improvements, trouble-shoots recurring problems that impact timely and complete resolution of grievances and appeals and escalates issues appropriately to Department management. Proposes solutions and improvements to address issues identified.
• Investigates and reviews complex situations and underlying issues, analyzes and solves problems. Identifies issues for escalation to Department management. Consults with the members, families, providers and health plan departments as necessary. Appropriately identifies and communicates key points from details.
• Investigates and coordinates the resolution of complex grievances and appeals according to defined processes and procedures ensuring that required time frames and regulatory requirements are met, that accurate and timely follow up is completed and that activities are documented as required.
• Reviews covered and coordinated services in accordance with established plan benefits, application of medical criteria and regulatory requirements to ensure appropriate appeal resolution and execution of the plan’s fiduciary responsibilities. Prepares records for physician review as needed.
• Conducts review of requests for prior authorization of health services, as required in certain product lines and prepares written response consistent with regulatory requirements.
• Assist in monitoring the process for cases undergoing external review, when requested by enrollees, including preparation and submission of documentation according to regulatory requirements and tracking external reviews throughout the process until completion. External reviewers include New York State (Fair Hearings), Centers for Medicare and Medicaid Services, Independent Review Entities and Quality Improvement Organizations.
• Collaborates with professionals, health plan departments such as Utilization and Care Management, Medical Directors, Compliance and Legal, as necessary,…