RN Health Plan Grievance & Appeals Specialist - Denver Health Medical Plan (Must Be a Colorado Resident)

We are recruiting for a motivated RN Health Plan Grievance & Appeals Specialist - Denver Health Medical Plan (Must Be a Colorado Resident) to join our team! We are here for life’s journey. Where is your life journey taking you? Being the heartbeat of Denver means our heart reflects something bigger than ourselves, something that connects us all: Humanity in action, Triumph in hardship, Transformation in health. Department Managed Care Administration Must Be a Colorado Resident Job Summary Under minimal supervision, the Registered Nurse, Grievance & Appeals is responsible for assessing and completing appropriate documentation for tracking and trending, including conducting all pertinent research, in order to evaluate, respond, and close grievances and appeals for Denver Health Medical Plan's members, member representatives, contracted rental networks, hospitals, physician groups, primary care physicians, specialty care physicians and other individual health care providers in accordance with the Plan's adjudication and determination policies. Ensures that all Member Grievances and Appeals and Provider Resubmissions, Reconsiderations and Appeals, including all incoming correspondence, are properly processed on a timely basis. Essential Functions: Maintains grievance and appeal information as well as supporting documentation in accordance with regulatory bodies for all lines of business at the Medical Plan. (10%) Notifies appropriate channels in compliance of all regulations and policies, while balancing the need to produce high quality work related to complex and sensitive issues. (10%) Proposes recommendations and decisions to all grievances and appeals through internal and external communications. (10%) Coordinates the compilation of appeal case files for transmission to third-party reviewers, physician reviewers, and independent reviewer entities. (5%) Maintains knowledge of current regulatory standards, internal policies, and procedures and ensures compliance at all times. (10%) Maintains knowledge and information on contract terms and benefit plans for all Plan lines of business. (5%) Consults and communicates effectively with Appeals Manager, senior leaders and other departments in the investigation and disposition of the grievance or appeals as deemed necessary or in compliance of regulatory requirements. (20%) Leverages both written and verbal communications; and ensures all provider resolution communications are timely, as well as organized, accurate, comprehensive, and crafted professionally. (10%) Conduct and Review Quality of Care Concern Complaints (10%) Perform Utilization Reviews for 1st Level Appeals by utilizing MCG (evidence-based medical criteria) (10%) Education: Associate's Degree Registered Nurse required Work Experience: 1-3 years experience in a managed care health insurance plan required. Previous grievance and appeals experience preferred. Licenses: RN-Registered Nurse - DORA - Department of Regulatory Agencies required Knowledge, Skills and Abilities: Ability to investigate and analyze appeals with a level of thoroughness and in a timely manner. Ability to listen effectively and appropriately respond to difficult and urgent situations. Demonstrates strong analytical and research skills and the ability to solve problems creatively, objectively, and rapidly. Excellent interpersonal and verbal communication skills, including conflict resolution and mediation. Ability to write summaries, prepare reports, and write comprehensive letters using proper grammar and sentence structure. Must have a thorough understanding and working knowledge of managed care, health insurance plans, regulatory, and other policies and procedures, including grievance and appeals practices. Has critical thinking skills, ability to prioritize issues, handles sensitive issues with confidentiality, tact, and diplomacy. Ability to cope with a very high volume of tasks on a tight timeline under demanding conditions. Ability to adapt to a constantly changing environment and ability to work independently and with a team. Proficiency with the Microsoft Office Suite Experience with Data Entry Software Familiarity with various office equipment Must Be a Colorado Resident Shift Days (United States of America) Work Type Regular Salary $72,400.00 - $112,200.00 / yr Benefits Outstanding benefits including up to 27 paid days off per year, immediate retirement plan employer contribution up to 9.5%, and generous medical plans Free RTD EcoPass (public transportation) On-site employee fitness center and wellness classes Childcare discount programs & exclusive perks on large brands, travel, and more Tuition reimbursement & assistance Education & development opportunities including career pathways and coaching Professional clinical advancement program & shared governance Public Service Loan Forgiveness (PSLF) eligible employer free student loan coaching and assistance navigating the PSLF program National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer Our Values Respect Belonging Accountability Transparency All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made. Denver Health is an integrated, high-quality academic health care system considered a model for the nation that includes a Level I Trauma Center, a 555-bed acute care medical center, Denver’s 911 emergency medical response system, 10 family health centers, 19 school-based health centers, Rocky Mountain Poison & Drug Safety, a Public Health Institute, an HMO and The Denver Health Foundation. As Colorado’s primary, and essential, safety-net institution, Denver Health is a mission-driven organization that has provided billions in uncompensated care for the uninsured. Denver Health is viewed as an Anchor Institution for the community, focusing on hiring and purchasing locally as applicable, serving as a pillar for community needs, and caring for more than 185,000 individuals and 67,000 children a year. Located near downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer. Denver Health is an equal opportunity employer (EOE). We value the unique ideas, talents and contributions reflective of the needs of our community. Applicants will be considered until the position is filled. Denver Health was founded as City Hospital in 1860 to serve the health care needs of the rapidly developing city of Denver. Since then, we have grown alongside the community to become a complete health care system, proudly providing care for all residents -- at every point in their lives. We believe healthy people are the foundation of a vibrant community, and Denver Health has been treating and healing the people of Denver for more than 160 years. Today, Denver Health delivers preventive, primary and acute care services. We are committed to making our community a healthy place to live, work and raise a family. You’ll see that commitment in the programs we offer, through the care we provide and in our determination to achieve continuous improvement so our community always has the best care available. As a comprehensive, integrated organization, we provide hospital and emergency care to the public, regardless of ability to pay. This integration promotes continuity of care for each patient and assures health care that is delivered in the most efficient, cost-effective setting. We care for: thirty-three percent of Denver's population annually; Denver Health sees nearly 1,200,000 total patient visits annually. one in three Denver-area children each year. the needs of special populations such as the poor, uninsured, pregnant teens, persons addicted to alcohol and other substances, victims of violence and the homeless. As Colorado's primary safety-net institution, Denver Health has provided uncompensated care and serves as a model for other safety net institutions across the nation.

Salary : $72,400 - $112,200