Appeals and Grievance Regulatory Specialist

Presbyterian Healthcare Services

1d • $48,069 - $73,403 • Onsite

About The Position

Build your Career. Make a Difference. Presbyterian is hiring a skilled Appeals and Grievance Regulatory Specialist to join our team.

Requirements

• Bachelor Degree, with 2 years experience in appeals and grievance or customer service

Responsibilities

• Responsible for reporting requirements and regulatory and contractual changes related to the complaint, appeals and grievance process and assists with identifying and responding to issues related to these processes.
• Under limited supervision, responds to and resolves complex issues related to daily operations, and overall management of the processes to meet regulatory and contractual requirements for oversight bodies of all product lines and to develop and create internal and external reports related to appeals and grievance data for member and providers of all product lines.
• Facilitates resolution of issues or process improvements by supporting multi-functional teams through data trending, tracking and analyzing.
• Acts as a resource to the complaints/grievances management staff by providing guidance for; development, training on policies, procedures, processes and reporting criteria requirements
• Effectively communicates with all levels of management staff.
• Escalates issues as necessary to include accurate documentation, research and suggested resolutions.
• Communicates trends and recommended resolution time frames.
• Assists with creating, developing and monitoring corrective action plans.
• Develops and presents training to employees as identified by the organization and the manager/director.
• Assists in collecting and coordinating performance reports and metrics.
• Presents performance indicators at meetings and facilitates discussion regarding trends and performance indicators.
• Supports and assists with complaint/grievance management audits to ensure that required processing standards are met and maintained in accordance with all applicable requirements.
• Prepares summary report of findings with recommendations for improvement.
• Responsible for all over sight reporting related to complaint management functions.
• Coordinates the collection of, performance indicators and regulatory reports on a monthly, quarterly and annual basis.
• Presents performance indicators at all applicable compliance meetings and facilities discussion regarding actions to take as a result of trends in performance indicators.
• Composes responses to RFPs for the health plan and other vendors, as well as commercial, PIC and Medicaid contracts as required and requested, based on data collected by appeals and grievance and complaint data processed in the department
• Supports department manager/director with special projects and/or initiative as needed.

Benefits

• medical
• dental
• vision
• short-term and long-term disability
• group term life insurance
• other optional voluntary benefits
• Wellness Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level