Customer Solution Center Appeals and Grievances Specialist III

Job Summary

The Customer Solution Center Appeals and Grievances Specialist III will receive, investigate and resolve member and provider complaints and appeals exercising strong independent judgment. This position will provide resolution of complaints in compliance with CMS, DHCS, DMHC, MBMIB and NCQA regulatory requirements. The position reviews pre-service authorizations, concurrent and post-service (retroactive review) medical necessity; benefit coverage appeals and reconsiderations, and complex provider claim disputes. The position is responsible for monitoring the caseloads of the Grievance Specialists and ensuring timely and accurate closure of grievances to meet regulatory requirements. The position is also responsible for overseeing the case resolution process and conducting quality checks to ensure that resolutions meet regulatory and internal requirements. The position is further responsible for tracking, trending and reporting complaints and appeals, as well as participating in internal and external oversight activities. The position is responsible for maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting noncompliance, adhering to company policy and procedures, including accreditation requirements, applicable federal, state and local laws and regulations. Acts as a Subject Matter Expert, serves as a resource and mentor for other staff.

Duties

Contacts members as needed to investigate, coordinate care and support resolutions for clinical and non-clinical cases. 

Identifies, investigates, and resolves administrative complaints, complex provider appeals and State Fair Hearing cases adhering to Centers for Medicare and Medicaid Services(CMS), California Department of Health Care Services (DHCS), California Department of Managed Health Care (DMHC), MRMIB and National Committee for Quality Assurance (NCQA) standards and regulations. 

Intakes, acknowledges, prepares case files and routes complaints to appropriate internal department for investigation and resolution, exercising strong independent judgment. Oversees members' case files in the applicable database/system to ensure that files are accurate and complete. Oversees caseloads for assigned specialists and provides coverage for assigned specialists who are absent.

Monitors daily/weekly/monthly grievance reports to ensure timeliness of case closures to meet internal and external reporting requirements. Prepares and analyzes monthly appeal and grievance reports to meet internal and external reporting requirements.

Participates in internal and external oversight activities, inter-rater reliability reviews and focused audits.  Recommends opportunities for improvement. 

Performs outreach to internal departments, Plan Partners, IPA/PPGs, facilities and vendors to gather information, medical records and other documentation as needed by nurse and in compliance with PP/PPG contracts.

Completes non-clinical aspects of Clinical Grievance Resolution Letter using appropriate template for type of case and LOB. Provides completed letter with attachments for nurse to approve. Arranges for translation of letter, if required, in time to meet regulatory timelines. Mails letter using department protocols. 

Applies subject expertise in evaluating business operations and processes. Identifies areas where technical solutions would improve business performance. Consults across business operations, providing mentorship, and contributing specialized knowledge. Ensures that the facts and details are correct so that the project’s/program's deliverable meets the needs of the department, organization and legislation's policies, standards, and best practices. Provides training, recommends process improvements, and mentors junior level staff, department interns, etc. as needed.

Performs other duties as assigned.

Duties Continued

Education Required

Education Preferred

Experience

Required:
At least 4 years of experience in managed care with specific experience in resolving member and provider complaint and appeals issues, including eligibility, access to care, claims, benefit, and quality of care concerns.   

 
Experience working with firm deadlines, able to interpret and apply regulations.  

Preferred:
Knowledge of Medical terminology and strong advocacy experience.

Skills

Required:
Must be organized, detail oriented, able to exercise strong independent judgment; poses conflict resolution and persuasion skills.

A team player with excellent communication and presentation skills, able to work effectively with various internal departments/service areas, plan partners, participating provider groups and other external agencies.

Proficient in MS Office applications, Word, Excel and Power Point.

Strong knowledge of regulatory standards and claims processing.

Strong analytical, verbal, written and presentation skills. 

Able to monitor and be compliant with strict regulatory deadlines. 

Preferred: 
Proficient in Access, Visio.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information

This position requires work after hours, on weekends, holidays, a hybrid remote schedule, occasional flexibility in hours/shift in critical situations and work on-call.

This position requires handling various caseloads and flexibility to adapt to changing priorities which may include but not limited to redistributed work assignments, team projects, and other priorities as assigned