Overview
Manages the day to day activities for staff handling of grievances and appeals for one of the following VNS Health Plans product lines – Managed Long Term Care (MLTC), Medicare Advantage (MA) or Select Health. Ensures compliance with state and federal regulatory requirements. Also monitors and audits subcontractors who have delegated responsibility for managing grievance and appeals on behalf of the plan to ensure operational and regulatory compliance. Maintains and ensures integrity of case file and data collection systems and prepares data reports and analysis of grievance and appeals for program management and committees, as needed. Works under general direction.Compensation Range:$109,900.00 - $146,500.00 Annual
What We Provide
- Referral bonus opportunities
- Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays
- Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life and Disability
- Employer-matched retirement saving funds
- Personal and financial wellness programs
- Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care
- Generous tuition reimbursement for qualifying degrees
- Opportunities for professional growth and career advancement
- Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities
What You Will Do
- Responsible for direct oversight and the day to day management of clinical appeals review processes within Appeals & Grievances Department.
- Manages the intake, investigation and resolution of member grievances and appeals for one of the following VNS Health Plans product lines - Managed Long Term Care (MLTC), Medicare Advantage (MA), Part D, or Select Health to ensure compliance with mandated regulatory processes and timeframes. Maintains readiness for DOH or CMS audit at all times.
- Ensures regulatory compliance and timely processing for the Medicare and Medicaid appeal and grievance processes, incidents, quality of care concerns and any other inquires requiring clinical review for medical necessity, appropriateness of service or clinical quality.
- Acts as subject matter expert to internal departments and delegated vendors to assure all are educated and compliant with requirements of appeals and grievance regulations and processing.
- Work closely with all members of the A&G team to continue streamlining A&G processes for continued improvement in staff knowledge, engagement with internal departments, STARS Measures, and enrichment of members experience with A&G.
- Tracks grievances and appeals that are in process in the department; ensures the integrity of tracking logs and records documenting plan actions and timeframes for each appeal or grievance.
- Communicates with corporate and regional staff at all levels including but not limited to, Provider Relations, Claims, Medical Director, third party administrator, pharmacy benefit manager, to achieve resolution of appeals and grievances.
- Ensures the accuracy and integrity of data collection and reporting systems to support analysis and reporting of grievances and appeals data for operations and for required CMS and DOH reporting. Participates in analyses and reports on grievance and appeal activity for management, committees, and regulatory entities. Analyzes trends and recommends departmental improvements.
- Manages and tracks appeals external to the plan including cases with the CMS independent review entities and NYS Fair Hearings. Supervises investigations and prepares a recommended responses to grievances referred to the plan from regulatory entities including but not limited to the Department of Health, CMS and Department of Insurance.
- Manages specialty subcontractors program for delegated grievance and appeal responsibilities. This includes review, analysis and auditing of subcontractors to evaluate compliance with delegated functions and with CMS or DOH regulatory requirements. Recommends and assists in development of audit criteria, conducts audits and prepares audit reports and recommends corrective action as needed; follows-up to ensure that corrective actions have been implemented.
- Prepares and disseminates reports and correspondence to enrollees, providers, regulatory entities and program staff and management as needed.
- Assists in the development and implementation of policies, procedures and operational workflows related to grievances and appeals. Recommends and assists in the development of standards and criteria for monitoring compliance with regulatory requirements for MLTC, MA and/or Select Health programs. Monitors and analyzes process flow for timeliness and efficiencies.
- Keeps up to date on the latest regulatory issues/requirements and trends in governing VNS Health Plans products through networking, professional memberships, and select journal reading. Identifies and recommends changes to plan grievance and appeal operations accordingly.
- Identifies, recommends, and develops action plans to improve grievance and appeal workflows and processes, service performance, regulatory compliance and quality standards.
- Serves as a resource on grievances, appeals and external reviews, focusing primarily on issues of medical necessity. Identifies and recommends key areas for training and coaching of staff based on departmental monitoring and oversight. Maintains and oversees staff leave schedules, ensures adequate staff coverage for departmental functions year-round, and holiday and weekend coverage.
- Maintains and supervises weekend on-call appeal processes.
- Performs all duties inherent in a managerial role. Ensures effective staff training, evaluates staff performance, provides input for the development of the department budget, and hires, promotes, and terminates staff and recommends salary actions as appropriate.
- Participates in special projects and performs other duties as assigned.
Qualifications
Licenses and Certifications:
- License and current registration to practice as a registered professional nurse in New York State required
Education:
- Associate's Degree in Nursing required
- Bachelor's Degree in Nursing preferred
Work Experience:
- Minimum of five years’ progressive professional experience in health care, including a minimum of three years’ experience in a Grievance and Appeals or related area such as medical or utilization management in a Managed Care setting required
- Experience in a supervisory role preferred
- Excellent oral and written communication skills required
- Computer literacy including word processing, spreadsheet applications, and database applications required. MS Office preferred
- Experience with FACETS system preferred
