Grievance & Appeals Specialist

• Referral bonus opportunities
• Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays
• Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life Disability
• Employer-matched retirement saving funds
• Personal and financial wellness programs
• Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care
• Generous tuition reimbursement for qualifying degrees
• Opportunities for professional growth and career advancement
• Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities

• Develops and maintains current knowledge of state and federal regulatory requirements related to all aspects of grievances and appeals for Medicare managed care organizations, Medicaid, home health care, managed long term care as well as contractual requirements.
• Investigates and reviews routine and complex situations and underlying issues, analyzes and solves problems. Consults with the member, family, providers and health plan departments as necessary. Identifies and communicates key points from details.
• Investigates and coordinates the resolution of routine and complex grievances and appeals according to defined processes and procedures ensuring that required timeframes and regulatory requirements are met, accurate and timely follow up is completed and activities are documented as required.
• Reviews covered and coordinated services in accordance with established plan benefits, application of medical criteria and regulatory requirements to ensure appropriate appeal resolution and execution of the plan's fiduciary responsibilities. Prepares records for physician review as needed.
• Conducts review of requests for prior authorization of health services, as required in certain product lines, and prepares written responses consistent with regulatory requirements.
• Coordinates external case reviews requested by enrollees, including preparing and submitting documentation according to regulatory requirements and tracking external reviews throughout the process. External reviewers include New York State (Fair Hearings), Centers for Medicare and Medicaid Services (CMS), Independent Review Entities and Quality Improvement Organizations.
• Collaborates with professionals, health plan departments such as Claims and Medical Management, and the third party administrator staff and legal, as necessary, to investigate and facilitate resolution of individual grievances and appeals. Consults with enrollees, providers and the Medical Director, as appropriate.
• Provides input and recommendations for design and development of policies, processes and procedures for improved department operations and customer service.
• Reviews information available from Medicaid, Medicare, other payers, and/or professional medical organizations regarding benefit levels and medical necessity criteria.
• Enters data and assists with compiling reports and analysis on the grievance and appeals process.
• For Fair Hearings:
• Supports Grievance and Appeals on legal issues pertaining to State Fair Hearings. Attends Fair Hearings in person with the Grievance and Appeals' RN Specialist and presents arguments in defense of the appeals.
• Works directly with outside counsel, as needed to ensure that the plan is competently represented at Fair Hearings.
• Assists in drafting waiver notices associated with Fair Hearings, as well as effectuation documents at the conclusion of the hearings. Researches and discusses relevant laws, regulations, and case law associated with the fair hearing process. Handles information requests related to the hearings.
• Updates department's database with Fair Hearing case information. * Participates in special projects and performs other duties as assigned.

Education:
Bachelor's Degree in health/human services, healthcare or business administration or related field or equivalent work experience required

Master's Degree in public health or health-related field preferred

Work Experience:
Minimum three years progressive professional experience in health care, including a minimum of two years in a grievance and appeals or related area such as medical or utilization management in a Managed Care setting required Proficient verbal/written communication skills required Proficient computer and typing skills and knowledge of Microsoft Office (Word and Excel) required Ability to work in a fast paced environment and effectively manage multiple grievances and appeals simultaneously.