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South Country Health Alliance · 1 day ago

Grievance and Appeals Specialist

Medford, MN

Full-time

Hybrid

Entry, Mid Level

$30/hr - $50/hr

2+ years exp

South Country Health Alliance is a mission-driven organization dedicated to improving health and well-being in rural Minnesota communities. They are seeking a temporary Grievance and Appeals Specialist who will manage member complaints and perform advanced case review duties requiring clinical judgment and independent analysis.

Health CareNon ProfitWellness

No H1B

Responsibilities

Processes member complaints and related requests thoroughly and completely by acquiring appropriate records and/or other information and applying problem-solving skills and investigative methodology. Cases will be processed in accordance with regulatory requirements and departmental policies and procedures, ensuring timely and proper resolution. Accurately interprets and applies policy and regulation

Contacts others as necessary to obtain case related information, which may involve obtaining the assistance of other SCHA staff for review/investigation of information; will collaborate effectively with others, including, but not limited to SCHA’s Chief Medical Officer and/or Medical Director, SCHA’s Health Services, Member Services and Operations departments, county staff, delegated entities and providers

Maintains accurate and complete case documentation, which includes both electronic and hard copy case files. Ensures related correspondence is scanned into the electronic record

Assist the G/A team with administrative functions, which may include, but is not limited to, returning phone calls, faxing correspondence, scanning and uploading documents, mailing letters and preparing case files

Conducts necessary and appropriate case preparation, interviews and record review. Collects information from a variety of sources, including members, providers and SCHA staff

Collects and compiles G/A data as directed, on a daily, monthly or quarterly basis

Updates G/A tracking tools, department spreadsheets and other documents as necessary

Professionally and accurately drafts correspondence as assigned

Assists with last minute urgent requests, which may include preparing case files for external reviewers

Performs other job duties as assigned within the scope, responsibility and requirements of the job

Qualification

Health plan experienceComplaint investigationsLPN/RN LicenseMicrosoft OfficeMedical terminologyCommunication skillsProblem-solving skillsOrganizational skills

Required

2 + years Health plan experience and/or experience conducting complaint investigations

Proficiency in Microsoft Office, especially Word and Excel

Familiarity with medical terminology

A knowledge of both State Public Programs (MN Medicaid) and Medicare (dual) products

Must be legally authorized to work in the U.S. (No sponsorship available)

Must be able to read and write in English; must communicate in an accurate, clear and concise manner

Basic Mathematical skills required

Must understand cause and effect relationships and be able to draw conclusions from data, regulatory requirements, and past practice

Preferred

A valid, unrestricted LPN License/ RN License is preferred

Current, valid, and unrestricted Minnesota LPN License and at least 2 years of health care experience

An equivalent combination of applicable education, professional training, and health care experience, which demonstrates the ability to successfully perform the responsibilities of this job, may be considered in lieu of a degree

Proficient in Microsoft Office, especially Word and Excel

Familiar with medical terminology

Health plan experience and/or experience conducting complaint investigations

Associate Degree Nurse with active, unrestricted Minnesota license also preferred