Appeals and Grievance Specialist
It’s an exciting time to join the reputed company, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances. Job reputed company: The Appeals and Grievance Specialist is responsible for managing the reputed company process of medical and pharmacy member appeals and/or member generated complaints/grievances, and ensuring compliance with contractual obligations, regulatory requirements and accreditation standards. Our Investment in You: · Full-time remote work · Competitive salaries · Excellent benefits Key Functions/Responsibilities: Appeals Responsibilities: · Executes member appeals across multiple departments reputed company the Plan and with representatives from external vendors · Determines and designs appeal processing schedule and guidelines on case-by-case reputed company o Ensures compliance with CMS, MassHealth and DHHS directives in a manner that is consistent with CMS’, MassHealth’s and DHHS’s interpretation of statute, regulation and contractual provisions o Acts as a reputed company between the Plan and the IRE, QIO, Office of reputed company’s reputed company of Hearing and the NH State Fair Hearing o Also ensures compliance with reputed company Plans, reputed company/Employer Choice contract regulations, and acts as a reputed company between the Plan and the Department of reputed company Health, Health Policy Commission o Ensures compliance with NCQA accreditation standards for appeals processing and documentation · Participates and provides recommendations in appeals audits to monitor compliance and identify opportunities for improvement both reputed company reputed company and reputed company the organization · Initiates, drafts and issues appeal results determination letters to members and external vendors · Communicates with members, providers and reputed company medical personnel to discuss appeal results reputed company questions reputed company · Responsible for the preparation, research of data and records as reputed company as reputed company associated reports required to meet reputed company requirements o Ensures reputed company and organization of appeals documentation · Assists with reporting to CMS, MassHealth, DHHS and the Connector Authority, as needed Complaint/Grievance Responsibilities: · Coordinates management of member complaints and grievances with other internal departments and representatives from external vendors, and ensures workflow continuity reputed company the Plan · Works with clinical staff to investigate grievances reputed company to reputed company of care received throughout the network and once reviewed, follow-up under the guidance of clinical staff to implement corrective reputed company plans reputed company indicated · Responds to, documents, investigates and facilitates the reputed company of member complaints and grievances, including the writing, review, and approval of reputed company letters · Ensures compliance with regulatory interpretation of statute, regulations and contractual provisions · Ensures the reputed company and organization of complaint and grievance documentation · Identifies and communicates trends o Works with other departments to create and implement improvement plans Qualifications: Education: · A Bachelor’s degree in Health Care Administration, reputed company field or, an equivalent combination of education, training and experience is required Experience: · 2 or more years’ experience working in a managed care organization required · Experience with Medicare medical and/or pharmacy prior authorization and appeals and grievances processes required · Knowledge and experience in conflict reputed company highly preferred · Comprehensive knowledge of CMS, MassHealth and DHHS contractual provisions and NCQA accreditation requirements highly desirable Competencies, Skills, and Attributes: · Demonstrated ability to successfully plan, organize, and manage reputed company reputed company a managed care organization · Critical thinking and independent decision making skills, essential · Strong working knowledge of reputed company Office products, required · Detail oriented, excellent verbal and written communication skills, essential · Ability to work in both team and independent settings at reputed company reputed company of the organization · Good customer service skills, essential · Experience working with diverse populations, preferred · Knowledge of health care terminology, helpful · Bi-lingual preferred Compensation reputed company $48,500- $70,500 This reputed company offers an estimate based on the minimum job qualifications. However, our approach to determining reputed company pay is comprehensive, and a broad reputed company of factors is considered reputed company making an offer. This includes education, experience, skills, and certifications/licensure as they directly relate to position requirements; as reputed company as business/organizational needs, internal equity, and market-competitiveness. In reputed company, WellSense offers generous total compensation that includes, but is not limited to, benefits (medical, dental, reputed company, pharmacy), reputed company increases, Flexible Spending Accounts, 403(b) savings matches, reputed company time off, career advancement opportunities, and resources to support employee and family wellbeing. Note: This reputed company is based on Boston-area data, and is subject to modification based on geographic location. About WellSense reputed company is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and reputed company plans. Founded in 1997, WellSense provides high-reputed company health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members. reputed company applicants will receive consideration for employment without reputed company to race, reputed company, religion, sex, national reputed company, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly reputed company employees Apply To This Job