Appeals & Grievances Program Advisor

Position Summary:

Appeals and Grievances Program Advisor monitors and supports the operations and compliance of the Appeals and Grievances department through many NCQA and other related quality program activities including: monthly case quality monitoring, coordination of training initiatives, coordination of Peer to Peer reviews with MDs, and preparation of case samples for audit review. This position works collaboratively with the AG Representatives and Management to support the development and maintenance of a quality program. This position will be responsible for reporting monthly quality results and identifying opportunities for improvement and training and areas on noncompliance. In addition to NCQA program support, this role will also support compliance with CMS and MassHealth requirements and will be asked to assist with data checks for audit preparation and Policy and Procedure updates as required by regulations.

Essential Duties & Responsibilities:

• Conduct monthly case review of a random sample of appeals and grievance cases against previously developed scorecard and Federal and State Regulations. Complete individual summary scorecards for Supervisor feedback.
• Track monthly scores on spreadsheet and report monthly to management, highlighting training opportunities based on analysis of results
• Schedule Peer to Peer calls between requesting MDs and CCA MDs, per NCQA requirements.
• Coordinate BOH hearings with external State Hearing Board
• Help with preparation of NCQA audit review files (and other department audits as necessary) by using Adobe to combine and label system screen shots and case letters based on detailed audit regulations.
• Assist in the updating of department Policies & Procedures based on updates from State and Federal Regulators
• Run regular quality checks of CMS Universes to ensure team is inputting all required data points to ensure department is audit ready for yearly Timeliness Audit and for a full program audit.
• Participate in data quality checks for regulatory reporting submissions by verifying data in Guiding Care and identifying missing attachments, etc
• Communicate and work collaboratively with AG Representatives, Resolution Specialist and Management to maintain and improve quality of operations.
• Act as a CCA content expert on State and Federal Grievance and Appeal regulations for all CCA products.
• Appropriately interpret, apply, and communicate CMS and State regulations.
• Other duties and projects as appropriate and assigned.
• Support and assist with process improvement activities to address complaint trends and enhance processes. Support A/G team in identifying and analyzing complaint trends and presenting this data within CCA.
• Support 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.

Required Education:

• Associate's Degree or equivalent experience in Appeals and Grievances

Desired Education:

• Bachelor's Degree (B.S. or B.A.) or an Associate's Degree with equivalent of at least 2 years of previous professional experience in a health care, case/care management administrative, or related position.

Required Experience:

• 2-4 years

Knowledge, Skills & Abilities:

• Must be a self-starter with a high degree of accountability and responsibility
• Commitment to the mission of the organization
• Exceptional attention to detail
• Ability to research regulations and guidelines
• 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 and Adobe

Languages:

• English