Grievance and Appeals Coordinator (44913)

The Grievance and Appeals Coordinator (Coordinator) position is responsible for intake of the appeal and complaint/grievance. The Coordinator is responsible for mailing the Grievance and Appeals Units (GAU) correspondences to members and providers. The Coordinator supports the department by in-taking, assigning, and monitoring the movement of assigned cases and external appeals. The Coordinator alerts the assigned staff when timelines are nearing expiration. The Coordinator is responsible for ensuring external appeal review agencies meet established resolution timelines and uses a rotating strategy to assign the external appeal cases to the next agency in the rotation. The Coordinator maintains organized, secure, and efficient record keeping processes and supports the GAU by ensuring correspondences to members and providers are timely. The Coordinator communicates with internal and external customers verbally or in writing, as required, and within established timelines to ensure timely and compliant acknowledgement and resolution of complaints/grievances and appeals. The Coordinator establishes and maintains collaborative and meaningful interdepartmental relationships within the organization.

Duties and Responsibilities:

Duties include but are not limited to:

• Responsible for intake of all Medicaid, Medicare and Commercial grievances, appeals, and complaints, including potential Quality of Care complaints or grievances.
• Responsible for scanning all Medicaid, Medicare and Commercial grievances appeals and complaints, that are received on paper, according to department protocol into e-format for departmental processing
• Generates timely and compliant initial member acknowledgment (verbal and/or written)
• Initiates electronic tracking of all grievances, appeals and complaints including scanning of documents as needed and attaching to the member record
• Intakes, processes, and monitors external appeals for Medicaid and commercial product lines
• Follow-up with responsible departments and delegated entities to ensure compliance
• Ensures final resolution letters are compliant and generated within the required timelines
• Quality checks member and provider facing letters and when appropriate obtains legal opinion on language
• Builds effective and successful interdepartmental relationships with all areas of the company and utilizes good communication and customer service skills in responding to internal and external inquiries about the grievance, appeal and complaint process while being able to respond quickly regarding the status.
• Collaborates with the designated GAU Reporting Analyst and GAU Manager to generate required reports on a pre-determined or ad hoc basis, including but not limited to CMS, EOHHS, OHIC and requirements and other reports as needed for analysis and trending
• Under the guidance of the Manager of GAU, collaborates with the designated GAU Reporting Analyst and GAU Manager to generate reports for including but not limited to CMS, EOHHS, OHIC audits, and participates in the compiling of all grievance, appeal, and complaint records selected for on-site audits
• Collaborate with the Legal Department, GAU Manager and other departments to respond to, facilitate and monitor Administrative Law Judge (ALJ) and State Fair Hearings
• Provides training to new team members as needed
• Other duties as assigned
• Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhoods Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents

Qualifications

Qualifications

Required:

• Associates Degree or sufficient relevant work experience to equate to the degree

• Proven ability to identify problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
• Beginner knowledge of medical terminology and/or experience with CPT and ICD-9/10 coding
• Beginner knowledge of state and federal laws and resources
• Strong prioritization and time management skills
• Excellent customer service orientation and phone etiquette
• Strong interpersonal skills

• Proficient in Microsoft Applications such as Excel, Word, PowerPoint and Outlook
• Intermediate experience with general Healthcare Management Systems
• Ability to use proprietary healthcare management system

Preferred:

• Associates Degree in business-related field
• Two (2)+ years experience in health care or health insurance environment
• Two (2) years experience with Medicare benefits and compliance
• Beginner knowledge of CMS regulations and Medicare Regulations related to grievance/complaints and appeals
• Beginner knowledge of Medicaid Rules applicable to complaints/grievance and appeals
• Beginner knowledge of Rules as they apply according to the Office of the Health Insurance Commissioner
• Experience in communicating with provider network
• Certified Professional Coder (CPC) certification
• Experience with claim payment and adjudication systems
• Business writing experience (relative to producing letters and other written forms of communication per industry standards)

Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.