Appeals and Grievance Specialist

WellSense Health Plan•Remote,

4d•$48,500 - $70,500•Remote

About The Position

The Appeals and Grievance Specialist is responsible for managing the resolution process of medical and pharmacy member appeals and/or member generated complaints/grievances, and ensuring compliance with contractual obligations, regulatory requirements and accreditation standards.

Requirements

A Bachelor’s degree in Health Care Administration, related field or, an equivalent combination of education, training and experience is required
2 or more years’ experience working in a managed care organization required
Experience with Medicare medical and/or pharmacy prior authorization and appeals and grievances processes required
Demonstrated ability to successfully plan, organize, and manage projects within a managed care organization
Critical thinking and independent decision making skills, essential
Strong working knowledge of Microsoft Office products, required
Detail oriented, excellent verbal and written communication skills, essential
Ability to work in both team and independent settings at all levels of the organization
Good customer service skills, essential

Nice To Haves

Knowledge and experience in conflict resolution highly preferred
Comprehensive knowledge of CMS, MassHealth and DHHS contractual provisions and NCQA accreditation requirements highly desirable
Experience working with diverse populations, preferred
Knowledge of health care terminology, helpful
Bi-lingual preferred

Responsibilities

Executes member appeals across multiple departments within the Plan and with representatives from external vendors
Determines and designs appeal processing schedule and guidelines on case-by-case basis
Ensures compliance with CMS, MassHealth and DHHS directives in a manner that is consistent with CMS’, MassHealth’s and DHHS’s interpretation of statute, regulation and contractual provisions
Acts as a liaison between the Plan and the IRE, QIO, Office of Medicaid’s Board of Hearing and the NH State Fair Hearing
Ensures compliance with Qualified Health Plans, Commercial/Employer Choice contract regulations, and acts as a liaison between the Plan and the Department of Public Health, Health Policy Commission
Ensures compliance with NCQA accreditation standards for appeals processing and documentation
Participates and provides recommendations in appeals audits to monitor compliance and identify opportunities for improvement both within the team and within the organization
Initiates, drafts and issues appeal results determination letters to members and external vendors
Communicates with members, providers and internal and external medical personnel to discuss appeal results when questions arise
Responsible for the preparation, research of data and records as well as all associated reports required to meet internal and external requirements
Ensures quality and organization of appeals documentation
Assists with reporting to CMS, MassHealth, DHHS and the Connector Authority, as needed
Coordinates management of member complaints and grievances with other internal departments and representatives from external vendors, and ensures workflow continuity within the Plan
Works with clinical staff to investigate grievances related to quality of care received throughout the network and once reviewed, follow-up under the guidance of clinical staff to implement corrective action plans when indicated
Responds to, documents, investigates and facilitates the resolution of member complaints and grievances, including the writing, review, and approval of resolution letters
Ensures compliance with regulatory interpretation of statute, regulations and contractual provisions
Ensures the quality and organization of complaint and grievance documentation
Identifies and communicates trends
Works with other departments to create and implement improvement plans