Appeals and Grievance Specialist Job in Boston, Massachusetts Us
Job Description
The Appeals and Grievance Specialist is responsible for managing the overall coordination, investigation, documentation and the resolution process of medical and pharmacy member appeals and/or member generated complaints/grievances, and ensuring compliance with contractual obligations, regulatory requirements and accreditation standards.
Key Functions/Responsibilities:
Appeals Responsibilities:
- Coordinates management of member appeals across multiple departments within the Plan and with representatives from external vendors.
- Ensures compliance with MassHealth directives in a manner that is consistent with MassHealth's interpretation of statute, regulation and contractual provisions. Acts as a liaison between the Plan and the Office of Medicaid's Board of Hearing. Also ensures compliance with the Commonwealth Care contract regulations, and acts as a liaison between the Plan and the Department of Public Health, Office of Patient Protection. Ensures compliance with NCQA accreditation standards for appeals processing and documentation.
- Participates in appeals audits to monitor compliance and identify opportunities for improvement both within the team and within the organization.
- Responsible for the preparation, research of data and records as well as all associated reports required to meet internal and external requirements. Ensures quality and organization of appeals documentation.
Complaint/Grievance Responsibilities:
- Coordinates management of member complaints and grievances with other BMCHP departments and representatives from external vendors, and ensures workflow continuity within the Plan.
- Works with clinical staff to investigate grievances related to quality of care received throughout the network and once reviewed, follow-up under the guidance of clinical staff to implement corrective action plans when indicated.
- Responds to, documents, investigates and facilitates the resolution of member complaints and grievances, including the writing, review, and approval of resolution letters.
- Ensures compliance with regulatory interpretation of statute, regulations and contractual provisions.
- Ensures the quality and organization of complaint and grievance documentation.
- Identifies and communicates trends. Works with other departments to create and implement improvement plans.
Qualifications:
Education:
- A Bachelor's degree in Health Care Administration, related field or, an equivalent combination of education, training and experience is required
Preferred/Desirable:
Experience:
- 2 or more years experience working in a managed care organization required.
- Experience with medical and/or pharmacy prior authorization and appeals process required.
Preferred/Desirable:
- Knowledge and experience in conflict resolution highly preferred
- Comprehensive knowledge of MassHealth contractual provisions and NCQA accreditation requirements highly desirable.
Competencies, Skills, and Attributes:
- Demonstrated ability to successfully plan, organize and manage projects within a managed care organization.
- Strong working knowledge of Microsoft Office products required.
- Detail oriented, excellent verbal and written communication skills essential. Ability to work in both team and independent settings at all levels of the organization.
- Good customer service skills essential. Experience working with diverse populations preferred. Knowledge of health care terminology helpful.
- Bi-lingual preferred.
Boston, MA, US
January 2, 2011
• Tags: Appeals and Grievance Specialist Job in Boston, Massachusetts Us • Posted in: General