Grievance and Appeals Specialist Clinical

• Opportunities for professional growth and career advancement
• Internal mobility and advancement opportunities

• Develops and maintains current knowledge of state and federal regulatory requirements related to all aspects of grievances and appeals for Medicare managed care organizations, Medicaid, home health care, managed long term care as well as contractual requirements.
• Investigates and reviews routine and complex situations and underlying issues, analyzes and solves problems, focusing primarily on issues of medical necessity, quality of care, long term services and supports, etc.. Consults with the member, family, providers and health plan departments as necessary. Identifies and communicates key points from details.
• Investigates and coordinates the resolution of routine and complex grievances and appeals according to defined processes and procedures ensuring that required timeframes and regulatory requirements are met, accurate and timely follow up is completed and activities are documented as required.
• Reviews covered and coordinated services in accordance with established plan benefits, application of medical criteria and regulatory requirements to ensure appropriate appeal resolution and execution of the plan's fiduciary responsibilities. Prepares records for physician review as needed.
• Conducts review of requests for prior authorization of health services, as required in certain product lines, and prepares written responses consistent with regulatory requirements.
• Coordinates external case reviews requested by enrollees, including preparing and submitting documentation according to regulatory requirements and tracking external reviews throughout the process. External reviewers include New York State (Fair Hearings), Centers for Medicare and Medicaid Services (CMS), Independent Review Entities and Quality Improvement Organizations.
• Collaborates with professionals, health plan departments such as Claims and Medical Management, and the third party administrator staff and legal, as necessary, to investigate and facilitate resolution of individual grievances and appeals. Consults with enrollees, providers and the Medical Director, as appropriate.
• Provides input and recommendations for design and development of policies, processes and procedures for improved department operations and customer service.
• Reviews information available from Medicaid, Medicare, other payers, and/or professional medical organizations regarding benefit levels and medical necessity criteria.
• Enters data and assists with compiling reports and analysis on the grievance and appeals process.
• Participates in special projects and performs other duties as assigned.

Licenses and Certifications:

License and current registration to practice as a registered professional nurse in New York State required

Education:

Bachelor's Degree or Master's Degree in Nursing preferred

Work Experience:

Minimum three years progressive professional experience in health care, including a minimum of two years in a grievance and appeals or related area such as medical or utilization management required Proficient verbal/written communication skills required Proficient computer and typing skills and knowledge of Microsoft Office (Word and Excel) required Ability to work in a fast paced environment and effectively manage multiple grievances and appeals simultaneously.