Grievance and Appeals Analyst

POSITION SUMMARY

Supports the Appeals Manager in the gathering of information to resolve 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.

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.
• 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 grievance.
• Collects, analyzes and interprets data collected and communicates results in person or in writing to Grievance and Appeals Manager.
• Responsible for reviewing, classifying, researching, investigating and resolving member complaints (grievances and/or appeals).
• 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. 
• 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 on a daily basis all cases in 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 management effectively.
• Act as a liaison to all company departments as necessary.
• Responsible for special assignments or projects as requested by management.

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 Medicaid 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 timeliness.
  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.

The above statements describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified.

All qualified applicants will receive consideration for employment based on merit, without regard to race, color, religion, sex, national origin, disability, protected Veteran Status, or any other characteristic protected by applicable federal, state, or local law.