Grievance and Appeals Quality Review Specialist

About the role

Identifies and resolves operational quality problems and inefficiencies within the Grievance & Appeals (G&A) department. Conducts daily reviews of G&A case files, letters, and database records against required criteria. Ensures compliance with VNS Health Plans policies and procedures, regulatory requirements and business practices. Prepares summary reports and provides recommendations to reduce errors and improve process performance. Works under general supervision. Hybrid position.

Responsibilities

• Participate and maintain current knowledge of state and federal regulatory and contractual requirements related to all aspects of grievances and appeals for Medicare and Medicaid managed care organizations.
• Serve as subject matter resource to team members, supervisors and management staff.
• Conduct daily detailed quality reviews of G&A department caseload, including database records, shared drive file folders, resolution documentation, and letter review.
• Provide feedback to staff on audit results; analyze and identify trends; and provide recommendations to management regarding opportunities to reduce errors and improve G&A processes and performance.
• Identify and assist with challenging cases and cases with greater potential impact on department compliance, STARS, and other Plan priorities.
• Provide coaching to staff if an urgent issue is identified.
• Troubleshoot recurring problems that impact timely and complete resolution of grievance and appeals; escalate issues to department management, as appropriate.
• Work with VNS Health Plans Education to ensure that all Grievance and Appeals-related training documents are updated with the most up-to-date information.
• Conduct training for new hires and existing staff.
• Collaborate with G&A and Operational leadership to identify training needs; develop curriculum to address needs.
• Evaluate effectiveness of the training, methods and materials.
• Revise existing training materials and programs based on evaluation, changing requirements or regulations, and feedback from internal/external customers.
• Analyze and communicate root cause of G&A audit findings.
• Document and implement remediation plans for errors/issues identified through root cause analysis or via other avenues.
• Produce performance-focused reports which include results trending, analysis summaries, conclusions and recommendations.
• Enter data and assist with compiling reports and analysis on the grievance and appeals process.
• Support management in creation of intra- and inter-departmental reporting of G&A data, as needed.
• Collaborate with professionals, health plan departments such as Claims, Medical Management and Legal, and the third party administrator as necessary to ensure accurate resolution of G&A cases.
• Participate in audits of vendors delegated for grievance and appeals; summarize findings; and monitor implementation of corrective actions.
• Assist with preparation of files and external facing documents for regulatory and customer audits.
• Assist with audits conducted by internal or external reviewers.
• Assist with execution of corrective action plans.
• Participate in special projects and perform other duties as assigned.

Qualifications

• Education: Bachelor's Degree in health care administration, human services or business administration or related discipline or the equivalent work experience in a related professional field required.
• Work Experience: Minimum four years professional experience in health care, including a minimum of two years in grievance and appeals in a Managed Care setting required.
• Excellent verbal/written communication skills required.
• Proficient computer and typing skills, and knowledge of Microsoft Office (Word and Excel) and database software required.
• Demonstrated ability to work in a fast paced environment and effectively manage multiple grievances and appeals simultaneously required.
• Experience in one or more of the following areas: Audits, Compliance, and Medicare/Medicaid reporting required.
• Excellent verbal and written, presentation, communication, and writing skills required.
• Demonstrated ability to work effectively with employees at all levels of the organization required.

Benefits

• 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, CEU credits, and advancement opportunities.

Pay

Pay Range: USD $70,200.00 - USD $87,700.00 per year.