Supervisor Of Grievances And Appeals

Position Summary:

As a part of the Grievances and Appeals team, this position investigates and finds resolution of complaints, grievances and member appeals based upon specific regulatory requirements. In addition, the assembly and preparation of State Fair Hearing/IRO packets as well as coordination and participation in State Fair Hearings. This role serves as the subject matter expert on complaints, grievances, appeals, and their processes. This position oversees the Grievance and Appeals Coordinators and also is responsible for State required reporting. This position will appeals meetings for multiple lines of business and report to Medical Operations and Quality Improvement Committees.

Essential Duties and Responsibilities:

• Receives, researches, resolves, tracks trends, and reports all complaints, grievances, and appeals for all lines of business.

• Maintains complaint, grievance, and appeal logs for all lines of business.

• Responsible for case development and resolution of all complaints, grievances, and appeals. The end-to-end process requires:

• Research issues and obtain additional documentation as applicable

• Reference and understand CCP's internal policies and procedures to frame decisions.

• Interpret regulations

• Resolve cases and make critical decisions

• Manage all duties within regulatory timeframes

• Finalize and send acknowledgment and resolution correspondence

• Oversees the resolution of member complaints, grievances, and appeals related to quality of care and service, medical necessity, plan benefits and payments to ensure compliance with state and federal regulations and NCQA standards.

• Coordinates monthly and ad hoc grievance and appeals committee meetings.

• Communicate grievance and appeals decision to the participant within regulatory guidelines for timeliness, adhering to the strictest of timeframes for urgent and non-urgent requests, as imposed by the various federal and state laws.

• Ensures thorough, accurate and timely processing of appeals using the internal appeals, independent external review or Medicaid Fair Hearing process.

• Analyze complaint, grievance and appeal data, develop trend reports and work with various committees to identify opportunities for improvement to increase member satisfaction.

• Monitor delegated partners in care complaint, grievance and appeal activity to ensure compliance.

• Partner with other business areas to identify issues and develop appropriate action plans to address deficiencies.

• Prepare comprehensive report for submission to the Agency for Healthcare Administration monthly and the Florida Healthy Kids Corporation quarterly.

• Report data and make recommendations to the appropriate internal committees and workgroups such as Medical Operations and the Quality Improvement Committee.

• Maintain thorough knowledge of contract requirements, accreditation standards, and new and existing laws and regulations.

• Develop, update, and maintain grievance and appeal policies and procedures to support new lines of business and reflect changes in contract language, accreditation standards and updates in laws or regulations.

• Design and implement departmental trainings to ensure quicker resolution of member issues and a better understanding of member appeal rights.

• Work with internal stakeholders in federal, state, and/or internal audits of grievance and appeals processes as well as data validation activities, as needed. Takes the lead in presenting appeals and all grievance documentation during a mock or actual audit.

• Perform other duties as necessary.

This job description in no way states or implies that these are the only duties performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by their supervisor or management.

Skills and Abilities:

• Problem solving- Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem solving situations; Uses reason even when dealing with emotional topics.

• Verbal communication-speaks clearly and persuasively in positive or negative situations; Listens and gets clarification; Responds well to questions; Demonstrates group presentation skills; Participates in meetings.

• Written communications-writes clearly and informatively; Edits work for spelling and grammar; Varies writing style to meet needs; Presents numerical data effectively; Able to read and interpret written information.

• Demonstrates flexibility with a willingness to learn and adapt to changes in regulations and task-related priorities, along with the ability to multi-task and meet firm deadlines.

• Ability to deescalate tense conversations with members and/or family members, helping find a solution or resolution to a complaint or grievance.

Work Schedule:

As a continued effort to provide a safe and productive work environment, Community Care Plan is currently following a hybrid work schedule. Staff are able to work from home 3 days a week and will report to the office 2 days a week.

*The company reserves the right to change the work schedules based on the company needs.

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear. The employee is frequently required to stand, walk, and sit. The employee may occasionally be required to stoop, kneel, crouch or crawl. The employee may occasionally lift and/or move up to 15 pounds.

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside/outside the office, travel to other offices, as well as domestic travel. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.

We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion.

Qualifications

• Must have high school diploma or General Education degree (GED); Associates degree preferred; and greater than 5 years related experience and/or training; or equivalent combination of education and experience.

• Managed Care experience including Long Term Care

• 5 years of health care experience.

• Conversant with HIPPA regulations, Medicaid, and CHIP.

• Working knowledge of Microsoft software products such as Word and Excel.