South Country Health Alliance · 1 day ago
Grievance and Appeals Coordinator
Medford, MN
Full-time
Hybrid
Mid Level
$37.14/hr - $45.43/hr
3+ years expSouth Country Health Alliance is seeking a Grievance and Appeals Coordinator to join their team. This role is responsible for managing member complaints and appeals, requiring clinical judgment and knowledge of regulatory procedures.
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, as well as clinical knowledge. Cases will be processed in accordance with regulatory requirements and departmental policies and procedures, ensuring timely and appropriate determinations
Coordinates the assigned case in its entirety, which may require obtaining the assistance of other South Country staff for review/investigation of information; will collaborate effectively with others, including, but not limited to South Country’s Medical Director, Health Services, Member Services and Operations departments, county staff, delegated entities and providers. Works closely with South Country’s Medical Director and other contracted clinicians, especially during review of quality-of-care complaints and appeals, to ensure necessary and timely completion of case related medical reviews
Maintains accurate and complete case documentation, which may include both electronic and hard copy case files. Ensures related correspondence is scanned into the electronic record
At times, may need to correspond with external regulatory agencies such as the Minnesota Department of Human Services (DHS), Centers for Medicare and Medicaid Services (CMS) and the Minnesota Department of Health (MDH). This would include work-related functions pertaining to State Appeals (also known as State Fair Hearings) and handling/processing of cases involving external independent review entities
Conducts necessary and appropriate case preparation, interviews, and record review. Upon initial receipt of complaint/request, reviews documentation and/or phone call(s) to ensure accurate identification and classification of concern(s) to properly route/process these cases. Job duties will also include appropriate triaging of cases to determine the need to expedite the cases and/or process in a timely manner according to the member’s health condition
Completes assigned duties related to internal and external data reporting; this may include tracking and analysis of complaints data on a daily, monthly or quarterly basis, and may involve preparation and timely submission of reports for South Country’s Quality Assurance Committee, Compliance Committee and mandatory annual CMS/quarterly DHS grievance and appeals data reports
As assigned, will conduct a review of member phone calls involving complaints and/or related requests for quality purposes; in follow-up to this, may need to provide feedback and/or additional guidance as needed to South Country staff who handled the member phone call and related request
As designated by South Country’s G/A Manager, completes daily monitoring and processing of any complaints received via CMS’s Health Plan Management System (HPMS), Complaints Tracking Module (CTM). In addition to this, tracks and monitors quarterly complaint data received from external providers/clinics
Other job duties as assigned within the scope, responsibility and requirements of the job
Qualification
Required
An active Minnesota RN License and broad based clinical background
3-5 + years Health plan experience and/or experience conducting complaint investigations
Proficiency in Microsoft Office, especially Word and Excel
Knowledge of federal and state regulatory requirements for appeals and grievances
Preferred
A B.A. or B.S in Nursing
Health plan experience and/or experience conducting investigations or processing appeals
Benefits
Medical
Dental
Vision
Health savings account contributions
PERA Pension
Paid holidays
Paid vacation
Paid sick time
And more.
Company
South Country Health Alliance
South Country Health Alliance is a county-based health plan that offers an array of Medicaid, Medicare and health promotion programs.
51-200 employees
Funding
Current Stage
Growth StageLeadership Team
Leota Lind
CEO
Recent News
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