Appeals and Grievance Specialist

Position Summary

Appeals and Grievances Specialist supports the Operations Department and the Appeals and Grievances team in a number of ways to ensure compliance on activities related to member complaints in the organization and improve the member experience. This position works collaboratively across many departments at Commonwealth Care Alliance (CCA) as well as externally to facilitate timely resolution of all grievances and appeals and ensures compliance with regulations. Additionally, this position is responsible for timely investigation and member outreach as well as supports the Appeal and Grievances team in creation, review and mailing of member communication related to appeal and grievances.

Supervision Exercised: No

Essential Duties & Responsibilities

Processing of Grievances & Appeals:

• Responsible for the progress of grievance and appeal intervention and resolution.
• Assure verbal and written responses are provided to members and/or other parties within the required timeframes.
• Assure timely completion of member verbal and written correspondence.
• Thoroughly document all member appeal and grievance related interactions and interventions into CCA database.

Member Outreach:

• Provide accurate, prompt, and courteous service in response to written and telephonic member complaints.
• Responsible for communication and member outreach related to the member complaint.
• Support creation, review, and mailing of notices to members to ensure prompt and courteous member
• communication and that the organization is compliant and meeting all strict deadlines.
• When necessary collaborate with care teams, clinical staff, family members, and other involved in providing care for our members.

Interdisciplinary Communication and Collaboration:

• Communicate and work collaboratively with CCA departments to help manage and resolve member appeals and grievances.
• Act as a liaison between multiple departments to ensure the timely and complete capture and processing of all grievances and appeals.
• Interdepartmental stakeholders include but are not limited to: quality; regulatory affairs/compliance; clinical, operations, pharmacy, dental, reporting, and member services.
• Supports the Senior Appeals & Grievance Coordinator and A/G Coordinator in day-to-day tasks and assignments.

Content Expert:

• Act as CCA's content expert on State and Federal Grievance and Appeal regulations for all CCA products.
• Appropriately interpret, apply, and communicate CMS and State regulations.
• Remain apprised of policy updates and update operational processes.

Complaints Monitoring:

• Supports daily monitoring of Medicare and EOHHS's Complaints Tracking & Management (CTM) Module and timely communication of next steps on complaints notification, intervention, and resolution.

Secondary responsibilities:

• Other duties and projects as appropriate and assigned.
• Supports and assist with process improvement activities to address complaint trends and enhance processes.
• Supports A/G team in identifying and analyzing complaint trends and presenting this data within CCA.
• Assist in the update of CCA's Appeal and Grievance Policy and Procedures as well as related Standard

Operating Procedures and workflows.

• Supports preparation of materials and data for internal and external audits of grievance and appeals processes as well as data validation activities, as needed.
• Supports the maintenance of updated data in Appeal/Grievance application of the member enrollment database system to ensure successful audit preparation; supports the review data for completeness and accuracy.

Working Conditions:

• Standard office conditions.

Required Education:

• Associate's Degree or equivalent experience

Desired Education:

• Bachelor's Degree (B.S. or B.A.) or an Associate's Degree with equivalent of at least one year of previous professional experience in a health care, case/care management administrative, or related position.

Required Experience:

• 0-2 years

Knowledge, Skills & Abilities (Required)

• Must be a self-starter with a high degree of accountability and responsibility
• Commitment of the mission of the organization
• Exceptional attention to detail
• Ability to research regulations and guidelines and adapt to print materials
• Ability to effectively work independently or collaboratively with others
• Excellent written/verbal communication and interpersonal skills
• Exceptional organizational skills
• Demonstrates excellent judgment
• Ability to meet strict, time sensitive deadlines
• Must be proficient with Microsoft Office, including intermediate level of Excel and Word or higher

Language(s):

• English
• Fluency in Spanish preferred