Appeals And Grievances Specialist

Job Purpose

Under the Direction of the Appeals & Grievances Manager, the Appeals and Grievance Specialist will review, investigate and resolve all Appeals & Grievances received from Center Light providers, non-contracted providers and participants (members), ensuring that all receive the highest level of service from Center Light Staff.

Under the Direction of the Appeals & Grievances Manager, the Appeals and Grievance Specialist will review, investigate and resolve all Appeals & Grievances received from Center Light providers, non-contracted providers and participants (members), ensuring that all receive the highest level of service from Center Light Staff.

• Investigates and responds to complaints, grievances and appeals in a consistent fashion, adhering to all regulatory, accreditation and internal processing timelines and guidelines.
• Conducts thorough investigations of all related participant/member, Staff and provider correspondence through a comprehensive fact finding review to understand all the issues involved, often by accessing confidential employee or member information in accordance with organizational and regulatory guidelines.
• Obtains required information from internal and external entities, including employees, contracted vendors, and state and federal regulatory agencies.
• Interfaces with various departments (claims, provider relations, etc.), delegated entities, Medical Groups and Network Physicians to ensure timely resolution of cases when additional discussions are required to assess submitted appeal and grievances.
• Determines response based on type of Grievance or Appeal submitted using independent judgement.
• Recommends final resolution of complaints, grievances and appeals to leadership, which may include recommending corrective action to be taken regarding employees, process, or policy.
• Prepares detailed written responses to all members, participants and providers regarding the resolution of the submission.
• Offer recommendations to Management related to customer service and retention ideas, based on the complaints review.
• Represent Center Light in court proceedings related to fair hearings and appeals.
• Represent Center Light at Fair hearing which will require 25 percent travel time.
• Represent Appeals and Grievance department at PACE sites requiring 75 percent travel time
• Provides all administrative related information and routes accordingly for proper clinical review
• Timely and accurately documents the grievance or appeal both electronically and in hard copy.
• Provides written acknowledgement of all member and provider correspondence to be utilised during investigations.
• Monitors daily and weekly pending report
• Prepares all initial and final adverse determination letters.
• Identifies potential quality of care issues and directs cases to the Quality Management Department for review as needed.
• Documents all activities/ notes and tracks status of appeal, grievance and findings in designated tracking systems
• Ensures that appeal and grievances calls are answered from the appeal and grievance phone queue within company standards.
• Provides weekly/monthly
  -Authorization Department/ finance reports for management team.
• Prepares reports for presentation at various committees, Quality Assurance Committee minutes and distributes to Committee Team Members
• Adheres to company and department policies and procedures.
• Demonstrated ability to manage multiple projects and be flexible.
• Performs other duties as assigned.

Education: Bachelors or Associates Degree in business, health care or related field.

Experience: Two years’ experience in a managed care healthcare setting with experience in Appeals and Grievances and claims preferable.

Must pass typing test of 40wpm

• Proficient knowledge in computer programs such as Microsoft Office, and other database programs a plus
• Bi-lingual (based on population of site location)
• Excellent verbal and written communication skills
• Excellent problem solving and analytical skills
• Accurate attention to detail with strong organisational skills
• Demonstrated ability to manage multiple projects and be flexible

Responsibilities and tasks outlined in this job description are not exhaustive and may change as determined by the needs of the company.

We are an affirmative action and equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, disability, age, sexual orientation, gender identity, national…