Grievance & Appeals Analyst

POSITION SUMMARY

Gathers information and resolves customer concerns presented as a grievance or appeal. Works closely with internal departments and providers' staff to obtain pertinent information in a timely manner and in compliance with regulatory requirements. Appropriately documents members' grievances and appeals, the pertinent information related to the concern, the steps taken to resolve the issue, and the resolution of the issue. Presents completed case resolution to the Grievances and Appeals Supervisor, Medical Director, or Chief Medical Officer for signature and maintain case files with all pertinent documents per CHG's policies and procedures.

COMPLIANCE WITH REGULATIONS

Works closely with all departments necessary to ensure that the processes, programs, and services are accomplished in a timely and efficient manner in accordance with CHG policies and procedures and in compliance with applicable state and federal regulations including Centers for Medicare and Medicaid Services (CMS) and/or Medicare Part D, Department of Managed Health Care (DMHC) and Department of Health Care Services (DHCS).

RESPONSIBILITIES

• Educates and assists members and their family members or authorized representatives of Medicare and Medi-Cal grievance and appeals rights.

• Determines member eligibility and utilization history using QNXT's membership, claims, prior authorization, and case management, complaint tracking systems.

• Prepares and mails resolution decision letters that meet Medi-Cal or Medicare (CMC) requirements for content and timeliness.

• Within established timeframes, communicates resolution to members or their authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid (CMS), the Department of Health Care Services (DHCS), and the Department of Managed Health Care (DMHC).

• Determines additional levels of appeals that member is entitled to and processes them in accordance with Medi-Cal and Medicare standards and requirements for timeliness.

• Analyzes data collected and coordinates with member's treating providers and pertinent departments to resolve member's grievances.

• Collects analyze and interpret data collected and communicates results in person or in writing to the Grievances and Appeals Supervisor, Medical Director, or Chief Medical Officer.

• Responsible for reviewing, classifying, researching, investigating, and resolving member complaints (grievances and/or appeals).

• Adheres to CHG's Appeals and Grievances policies are based on Medicare Managed Care Manual Chapter 13 and Title 22, pertaining to the processing of Medicare grievances and appeals.

• Responsible for addressing and forwarding quality of care complaints to quality management for resolution.

• Responsible for documenting and maintaining pertinent files on all cases in the grievances and appeals platform (Innovare).

• Participate in regular meetings to review case logs and other matters as assigned.

• Responsible for compiling, preparing, and reporting all compliance and grievance data monthly.

• Responsible for formulating/implementing and executing all processes, requests, workflow, or policies as requested by management in a courteous and efficient manner, including offering a proactive approach to suggestions and recommendations and working or cooperating with Appeals and Grievance Manager or managed effectively.

• Act as a liaison to all company departments as necessary.

• Responsible for special assignments or projects as requested by management.

Qualifications

Education

• Bachelor's Degree Required

Experience

• Four years' experience either processing grievances within a managed care setting or in customer services within a Medi-Cal or Medicare environment.

• Full working knowledge of medical terminology, Medi-Cal, and Medicare-covered benefits.

• Knowledge of Medi-Cal and Medicare standards and requirements.

• Excellent verbal and written communication skills.

• Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA).

• Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers, and customers

• Ability to integrate and analyze information from several sources and problem solve towards a resolution within tight timelines.

Ability to interact with both internal and external customers along with strong organizational and time management skills.

• Must be able to accomplish duties and assignments with minimal supervision.

Physical Requirements

• Prolonged periods of sitting and frequent walking.

• May be required to work evenings and weekends.

• Position may at times require weekend overtime and or travel to attend seminars.

Must have current authorization to work in the USA

Community Health Group is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment based on any protected characteristic as outlined by federal, state, or local laws. This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, and trainings. Community Health Group makes hiring decisions based solely on qualifications, merit, and business needs at the time. For more information, see Personnel Policy 3101 Equal Employment Opportunity/Affirmative Action .