Appeals & Grievances State Quality Assurance Specialist

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Position Description

As the Appeals and Grievances (A&G) State Quality Assurance Specialist, you will be responsible for the oversight of key quality and compliance components of the appeal and grievances processes. You will ensure Centers for Medicare and Medicaid Services (CMS), Minnesota Department of Health (MDH) & NCQA regulatory adherence by coordinating staff training; contributing to creating and/or updating policies, procedures, work instructions and letters; and perform compliance reviews of A&G processes and files. In partnership with the A&G Senior Manager, create, develop and implement audit strategies to assist with compliance reviews. Perform case work as directed by the A&G Senior Manager.

• Audit appeals and grievances cases to ensure they are processed according to DHS, CMS, MDH & NCQA standards. Provide weekly results to AG leadership.

• Mentor and assist with training and onboarding new team members in appeals and grievances. Support specialists as they are learning new case types, including presenting cases at State Fair Hearings (SFH).

• Hold weekly State QA meetings with the State Specialist team to answer question and provide QA guidance and SME support.

• Identify and research trends or issues and recommend changes to enhance appeals and grievances processes. Identify knowledge gaps and training opportunities to enhance staff performance.

• Responsible for updating work instructions, policies and procedures and letters for all State appeals and grievances.

• Serve as a primary resource for Appeals and Grievances requirements for DHS related questions for internal staff and all departments at UCare. Collaboratively work with State Government Relations, Legal, DHS, NCQA to confirm guidance, as needed. Use system to log regulatory updates for the team's reference.

• Keep current on appeals and grievances case processing and intake processes by maintaining a small caseload and serving as a backup for staff as they are out of the office or as needed during times of high volumes. Assist with escalated, complex cases and late referrals by reporting to A&G leadership.

• Complete DHS reporting and support CMS reporting, as needed

• Accurately interpret incoming appeals and grievances to assist with determining the validity of cases by utilizing health plan member certificates of coverage, provider contracts, state and federal rules and regulations, and UCare policies and procedures.

• Participate in cross departmental meetings and workgroups as the A&G subject matter expert. Collaborate with other UCare departments, committees, and external departments on process improvements. Provide updates to AG leadership and to the team regarding the meetings/workgroups.

• Report late referrals and possible compliance concerns to AG Leadership.

• Attend all State GR meetings and maintain excellent understanding of requirements.

• Collaborate with AG leadership to effectively communicate compliance requirements to all stakeholders and create periodic update briefs and educational tools and resource to increase AG staff knowledge of the healthcare regulatory environment.

• Use and maintain Compliance 360 to ensure timely documentation of identified issues as well as provide updates on assigned activities according to deadlines. Develop workflows and track implementation progress for new regulatory guidance.

• Assist with the yearly material reviews for appeals and grievances letters and complete the submission of letters. Work with Materials to implement and communicate the letter changes to the Appeals and Grievances team.

• Other projects and duties as assigned.