This position manages the day-to-day operations of the Appeals and Grievances operations for our Medicaid Health Plan - HSCSN. Assures that the department is compliant with all regulatory requirements, manages turnaround times, submit reports to the executive leadership team, develops strategies to improve processes. This position has three direct reports and is a hybrid telework position.
Qualifications
Minimum Education
Bachelor's degree in healthcare related field - required
Minimum Work Experience
5 years Appeals and Grievances experience - required
3 years Managed Care experience - required
3 years Acute, Med-Surg, or Ambulatory care experience in a clinical role - required
Required Licenses
Registered Nurse DC preferred/Compact - preferred • Supervise the Grievance and Appeals team to ensure appropriate handling of member appeals and grievances. • Serves as the organization's subject matter expert on the Chart Retrieval & Clinical Review platform, including interactions with and impacts on adjacent services. Maintains appropriate documentation to meet regulatory reviews. • Ensure that all appeals and grievances are investigated thoroughly and resolved in compliance with regulatory requirements. • Conduct periodic reviews and audits to ensure quality and performance standards are met. • Develop and maintain records of appeals and grievances for reporting and auditing purposes. • Prepare and submit documents in response to fair hearings processes and requests; engage internal legal counsel as necessary. • Prepare and develop reports for, and present to, management related to appeals and grievances and fair hearings. • Ensure strict adherence to contractual requirements and Medicaid regulations, policies, and procedures. • Stay informed about changes in health care regulations related to appeals and grievances, and update processes accordingly. • Prepare and submit required reports to regulatory authorities regarding appeals, grievances and fair hearings activities. • Provide guidance, mentorship, and training to appeals, grievances, and risk management staff. • Foster a culture of compliance, quality improvement, and patient-centered care. • Identifies potential conflicts when reviewing and resolving appeals and grievances and escalates such conflicts to appropriate leader for review and resolution. • May perform other duties in addition to those outlined in this job description.