Grievance and Appeals Quality Review Specialist

• Referral bonus opportunities
• Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays
• Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life Disability
• Employer-matched retirement saving funds
• Personal and financial wellness programs
• Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care
• Generous tuition reimbursement for qualifying degrees
• Opportunities for professional growth and career advancement
• Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities.

• Participate and maintains current knowledge of state and federal regulatory and contractual requirements related to all aspects of grievances and appeals for Medicare and Medicaid managed care organizations. Serves as subject matter resource to team members, supervisors and management staff.
• Conducts daily detailed quality reviews of G&A department caseload, including database records, shared drive file folders, resolution documentation, and letter review. Provides feedback to staff on audit results; analyzes and identifies trends; and provides recommendations to management regarding opportunities to reduce errors and improve G&A processes and performance.
• Identifies and assists with challenging cases and cases with greater potential impact on department compliance, STARS, and other Plan priorities.
• Provides coaching to staff if an urgent issue is identified. Trouble-shoots recurring problems that impact timely and complete resolution of grievance and appeals; escalates issues to department management, as appropriate.
• Works with VNS health Plans Education to ensure that all Grievance and Appeals-related training documents are updated with the most up-to-date information. Conducts training for new hires and existing staff.
• Collaborates with G&A and Operational leadership to identify training needs; develops curriculum to address needs. Evaluates effectiveness of the training, methods and materials. Revises existing training materials and programs based on evaluation, changing requirements or regulations, and feedback from internal/external customers.
• Analyzes and communicates root cause of G&A audit findings. Documents and implements remediation plans for errors/issues identified through root cause analysis or via other avenues.
• Produces performance-focused reports which include results trending, analysis summaries, conclusions and recommendations. Enters data and assists with compiling reports and analysis on the grievance and appeals process. Supports management in creation of intra-and inter-departmental reporting of G&A data, as needed.
• Collaborates with professionals, health plan departments such as Claims, Medical Management and Legal, and the third party administrator as necessary to ensure accurate resolution of G&A cases.
• Participates in audits of vendors delegated for grievance and appeals; summarizes findings; and monitors implementation of corrective actions.
• Assists with preparation of files and external facing documents for regulatory and customer audits. Assists with audits conducted by internal or external reviewers. Assists with execution of corrective action plans.
• Participates in special projects and performs other duties as assigned.

Bachelor's Degree in health care administration, human services or business administration or related discipline or the equivalent work experience in a related professional field required

Minimum four years professional experience in health care, including a minimum of two years in grievance and appeals in a Managed Care setting required

Excellent verbal/written communication skills required

Proficient computer and typing skills, and knowledge of Microsoft Office (Word and Excel) and database software required

Demonstrated ability to work in a fast paced environment and effectively manage multiple grievances and appeals simultaneously required

Experience in one or more of the…