Appeals And Grievances Lead

GOLD KIDNEY CORE VALUES:

Gold Kidney Health Plan is a people business. Our success depends on having the best and brightest employees and helping them attain their personal and professional goals while delivering excellence in patient care and business results. Our employees embody our culture, which is based on six core values supporting our promise to improve the quality of life of every patient every day. These core values are Patients and Partners First, Honesty and Integrity, Quality and Compliance, Collaboration, No-Limits Mindset and Results Oriented.

PURPOSE AND SCOPE:

The Appeals and Grievances Lead is responsible for all Grievances, CTM’s and Appeals received. The incumbent will work independently on each item to resolution through research and coordination with other departments.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

· Identify, research, and resolve related Grievances/ CTM and Appeals (internal as well as external) ensuring compliance with policies and procedures and any applicable regulations.

· Identify, track and respond to Quality-of-Care Complaints

· Maintain tracking logs and case files in a database.

· Communicate with impact to members, providers, and vendors verbally and in writing.

· Prepare summaries, develop solutions, and write resolution letters for members and providers, which includes summarizing the appeal and the appeal process in clear and grammatically correct language within the appropriate timeliness standard.

· Prepare cases that require clinical review for A&G RN/Medical Director review.

· Review trends and work with other departments to resolve systemic issues that may prevent future grievances and appeals.

· Prepare agenda for the monthly Grievance meeting and lead the meeting for resolution of identified preventable Grievances with department business owners.

· Understand and distinguish between appeals and grievances and route correspondence to the proper department.

· Review and analyze weekly, monthly, quarterly, and year end A&G reports for distribution.

· Promote a provider-friendly, customer service-oriented philosophy within the Fresenius Health Partners Utilization Management department.

· Ensure that all department activities follow applicable CMS, NCQA, URAC or general accreditation standards, as well as State and other federal regulatory requirements.

· Maintain strict confidentiality of employee and organizational information in accordance with HIPAA and State privacy regulations.

· Serve as contact person for A&G letter updates/changes.

· Subject Matter Expert for ODAG/CDAG reporting and CMS audits related to Appeals and/or Grievances.

· Subject Matter Expert for Appeals and Grievances. Can provide training and/or training documents to other departments or new employees.

· Identify process improvements for the department and implement them with assistance from the Leadership team.

· Provide Grievance training and refresher training to member facing teams at Gold Kidney.

· Other duties as assigned.

PHYSICAL DEMANDS AND WORKING CONDITIONS:

· The physical demands and work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

SUPERVISION:

· None

EDUCATION:

· Bachelor’s Degree desirable or equivalent work history may be considered.

EXPERIENCE AND REQUIRED SKILLS:

· 2 – 4 years’ related experience required

· Medicare Advantage Appeals and Grievance experience required.

· Excellent analytical and leadership skills.

· Communicate effectively and professionally, both verbally and in writing.

· Track and trend data within the department and be willing to present at meetings

· Summarize information clearly and thoroughly in writing.

· Use sound judgment to identify next steps and develop appropriate solutions.

· Exceptional time management skills.

• Must be organized and meticulous, with a strong bias for follow-up and problem resolution.
• · Strong computer skills with demonstrated proficiency in word processing, spreadsheet, database, presentation and email applications.