[Hiring] Appeals and Grievance Specialist @WellSense Health Plan

Role Description

The Appeals and Grievance Specialist is responsible for managing the resolution process of medical and pharmacy member appeals and/or member generated complaints/grievances, and ensuring compliance with contractual obligations, regulatory requirements and accreditation standards.

Qualifications

• A Bachelor’s degree in Health Care Administration, related field or, an equivalent combination of education, training and experience is required
• 2 or more years’ experience working in a managed care organization required
• Experience with Medicare medical and/or pharmacy prior authorization and appeals and grievances processes required
• Knowledge and experience in conflict resolution highly preferred
• Comprehensive knowledge of CMS, MassHealth and DHHS contractual provisions and NCQA accreditation requirements highly desirable
• Demonstrated ability to successfully plan, organize, and manage projects within a managed care organization
• Critical thinking and independent decision making skills, essential
• Strong working knowledge of Microsoft Office products, required
• Detail oriented, excellent verbal and written communication skills, essential
• Ability to work in both team and independent settings at all levels of the organization
• Good customer service skills, essential
• Experience working with diverse populations, preferred
• Knowledge of health care terminology, helpful
• Bi-lingual preferred

Requirements

• Executes member appeals across multiple departments within the Plan and with representatives from external vendors
• Determines and designs appeal processing schedule and guidelines on case-by-case basis
• Ensures compliance with CMS, MassHealth and DHHS directives
• Acts as a liaison between the Plan and the IRE, QIO, Office of Medicaid’s Board of Hearing and the NH State Fair Hearing
• Ensures compliance with Qualified Health Plans, Commercial/Employer Choice contract regulations
• Ensures compliance with NCQA accreditation standards for appeals processing and documentation
• Participates and provides recommendations in appeals audits
• Initiates, drafts and issues appeal results determination letters to members and external vendors
• Communicates with members, providers and internal and external medical personnel
• Responsible for the preparation, research of data and records
• Ensures quality and organization of appeals documentation
• Assists with reporting to CMS, MassHealth, DHHS and the Connector Authority
• Coordinates management of member complaints and grievances
• Works with clinical staff to investigate grievances related to quality of care
• Responds to, documents, investigates and facilitates the resolution of member complaints and grievances
• Ensures compliance with regulatory interpretation of statute, regulations and contractual provisions
• Ensures the quality and organization of complaint and grievance documentation
• Identifies and communicates trends
• Works with other departments to create and implement improvement plans

Benefits

• Full-time remote work
• Competitive salaries
• Excellent benefits

Compensation Range

$48,500- $70,500. This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer.