Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015.
The Grievance Specialist demonstrates knowledge and expertise in processing Generations Advantage and US Family Health Plan grievances to ensure compliance with regulatory bodies, including but not limited to CMS, NCQA, Tricare requirements, etc. In addition, the role will provide cross-coverage for appeals, as needed. The Grievance Specialist collaborates with internal stakeholders to ensure a comprehensive review and resolution of each grievance. The Grievance Specialist plays a key role in maintaining compliance across Health Plan operations. This position receives, processes, investigates, and resolves member grievances for Martin’s Point Health Plans, providing verbal and written resolutions to multiple stakeholders, including members, providers, state and federal regulators, and leadership—in accordance with Plan processes, policies, and regulatory requirements.
Job Description
PRIMARY DUTIES AND RESPONSIBILITIES
- Manages the intake, triage, processing, research, investigation, and resolution of member complaints and grievances, ensuring full compliance with departmental and regulatory standards.
- Prepares grievance documentation in accordance with contractual requirements, including but not limited to acknowledgment letters, closure letters, medical record requests, external review submissions, and general correspondence.
- Demonstrates advanced knowledge and expertise in processing Generations Advantage and US Family Health plan grievances. This includes expertise in case classification, investigation, and de-escalation.
- Demonstrates advanced knowledge of claims processing and health plan benefits necessary for the Grievance Specialist to exercise decision-making authority to reprocess claims in accordance and alignment with regulatory and internal policies.
- Independently and with judgement, conducts multi-faceted, complex investigations through claims review, provider credentialing, authorization processing, Host system information, timeliness evaluations, and plan benefits design.
- Maintains and manages multiple work queues in alignment with regulatory timeframes and internal performance policies. These include inbound mail, fax, voicemail, internal communication platforms and an electronic Grievance management system.
- Responsible for all written and verbal communication with external downstream-entities, provider offices, customers and internal business partners as needed.
- Drafts and issues regulatorily compliant communications requiring advanced knowledge necessary to analyze, interpret and respond promptly to the requests based on facts and circumstances of the case.
- Prepares files and participates in both internal and external auditing activities as needed. These reviews may include activities such as the Defense Health Agency (DHA) Annual review, NCQA certification audit, CMS Data Validation audits, CMS Full Program audits, internal audits, and, ad-hoc reviews.
- Skillfully conducts provider and beneficiary outreach for the purposes of investigation and resolution of grievances, including outreach to provider billing offices and facilities.
- Assists in the review of policies, procedures, forms, workflow and letter templates no less than annually.
- Identifies trends and training opportunities and communicates them to leadership as appropriate.
- Provides quality oversight of all grievances, letters, documentation to ensure compliance with privacy and HIPAA requirements.
- Participates and conducts internal system upgrade testing as required.
- Maintains responsibility for meeting required decision-making and communication timeframes after hours and on holidays to ensure full compliance with all regulatory and statutory requirements.
- Remains a subject matter expert and a key contact to assist with internal customer questions.
- Performs all other duties as assigned.
Employees are expected to work consistently to demonstrate the mission, vision, and core values of the organization.
POSITION QUALIFICATIONS
Education
- Bachelor’s Degree or equivalent experience and education.
Experience
- 3+ years of experience in managed care plan required.
Knowledge
- Knowledge of grievances and appeals required.
Skills
- Excellent written and verbal communication skills.
- Effective time management skills and organization skills.
- Must have a track record of producing high-quality work: highly accurate, demonstrates attention to detail, and reflects well on the organization.
- Strong interpersonal skills and the ability to collaborate with internal and external clients.
- Excellent customer services skills.
- Strong analytical, problem-solving and mathematical skills.
- Proficiency in Microsoft Office applications (Word, Excel, PowerPoint).
- Self-driven and self-motivated: ability to function independently with sound decision making skills.
- Ability to take appropriate initiative while soliciting input/advice appropriately.
Abilities
- Ability to handle confidential and sensitive information in a discreet and professional manner.
- Ability to handle high volume of work while maintaining accuracy and timeliness requirements.
This position is not eligible for immigration sponsorship.
We are an equal opportunity/affirmative action employer.
Martin's Point complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact [email protected]
Do you have a question about careers at Martin’s Point Health Care? Contact us at: [email protected]
Skills Required
- Bachelor's degree or equivalent combination of education and experience
- At least 3 years of experience in a managed care plan
- Knowledge of grievances and appeals
- Excellent written and verbal communication skills
- Effective time management and organizational skills
- High accuracy and attention to detail
- Strong interpersonal and collaboration skills
- Excellent customer service skills
- Strong analytical, problem-solving, and mathematical skills
- Proficiency in Microsoft Office applications, including Word, Excel, and PowerPoint
- Ability to work independently and make sound decisions
- Ability to handle confidential and sensitive information discreetly
- Ability to manage high-volume work while maintaining accuracy and timeliness
What We Do
Martin’s Point Health Care is an innovative not-for-profit health care organization offering high-quality, affordable health care and coverage to the people of Maine and throughout New England. Martin’s Point has seven health care centers in Maine and New Hampshire offering primary and specialty care to those with most major health insurance plans. Martin’s Point also administers two health insurance plans: Generations Advantage—with the only 5-Star Medicare Advantage plans in northern New England, and the US Family Health Plan for active duty military families and retirees throughout most of northern New England and New York. We believe that understanding both the clinical and health plan administrative side gives us the insight we need to make meaningful improvements to the health care system. Martin’s Point is dedicated to creating a community of healthy people through authentic relationships and trust
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