Grievance and Appeals Specialist

South Country Health Alliance•Medford, MN

4d•$30 - $50•Hybrid

About The Position

South Country Health Alliance is seeking a temporary Grievance and Appeals Specialist to join our team! This role is responsible for the management of assigned caseload involving member complaints received at South Country Health Alliance (SCHA), which may include member grievances or appeals. This department performs advanced and complicated case review duties requiring clinical judgment, independent analysis and detailed knowledge of departmental and regulatory procedures.

Requirements

2 + years Health plan experience and/or experience conducting complaint investigations
Proficiency in Microsoft Office, especially Word and Excel
Familiarity with medical terminology
A knowledge of both State Public Programs (MN Medicaid) and Medicare (dual) products
Must be legally authorized to work in the U.S. (No sponsorship available)
Follows direction and completes assigned job tasks independently
Performs job duties within his/her scope of practice
Accurately categorizes requests and issues proper notices
Demonstrates excellent written and verbal communication skills
Ability to work cross departmentally and effectively with business partners including Third Party Administrators (TPAs), health care providers and professionals
Ability to multi-task, prioritize assigned tasks and work effectively under pressure
Must be able to read and write in English; must communicate in an accurate, clear and concise manner.
Basic Mathematical skills required.
Must understand cause and effect relationships and be able to draw conclusions from data, regulatory requirements, and past practice.

Nice To Haves

A valid, unrestricted LPN License/ RN License is preferred
Current, valid, and unrestricted Minnesota LPN License and at least 2 years of health care experience.
An equivalent combination of applicable education, professional training, and health care experience, which demonstrates the ability to successfully perform the responsibilities of this job, may be considered in lieu of a degree
Associate Degree Nurse with active, unrestricted Minnesota license also preferred.

Responsibilities

Processes member complaints and related requests thoroughly and completely by acquiring appropriate records and/or other information and applying problem-solving skills and investigative methodology.
Cases will be processed in accordance with regulatory requirements and departmental policies and procedures, ensuring timely and proper resolution.
Accurately interprets and applies policy and regulation.
Contacts others as necessary to obtain case related information, which may involve obtaining the assistance of other SCHA staff for review/investigation of information; will collaborate effectively with others, including, but not limited to SCHAs Chief Medical Officer and/or Medical Director, SCHAs Health Services, Member Services and Operations departments, county staff, delegated entities and providers.
Maintains accurate and complete case documentation, which includes both electronic and hard copy case files. Ensures related correspondence is scanned into the electronic record.
Assist the G/A team with administrative functions, which may include, but is not limited to, returning phone calls, faxing correspondence, scanning and uploading documents, mailing letters and preparing case files.
Conducts necessary and appropriate case preparation, interviews and record review.
Collects information from a variety of sources, including members, providers and SCHA staff.
Collects and compiles G/A data as directed, on a daily, monthly or quarterly basis.
Updates G/A tracking tools, department spreadsheets and other documents as necessary.
Professionally and accurately drafts correspondence as assigned.
Assists with last minute urgent requests, which may include preparing case files for external reviewers.
Performs other job duties as assigned within the scope, responsibility and requirements of the job.