• Grievance and Appeals Clinical Specialist

    Job Locations US-RI-Smithfield
    Req No.
    NHPRI Department
    505 - Grievance & Appeals
    Regular Full-Time
  • Overview

    • The Grievance and Appeals Clinical Specialist is position is responsible for receiving, researching and facilitating resolution of member or provider-initiated clinical appeals. Determines applicable compliance criteria based on Medicaid, Medicare, and Commercial regulations and ensures workflow is managed to compliance turnaround times. The Specialist interprets and explains the company’s benefits, policies and procedures to members and providers as they relate to appeals. The Specialist will also track and monitor movement of assigned cases through functional units and systems while ensuring that resolution meets established timelines.
    • The Specialist communicates with members and providers either verbally or in writing as required and within established timelines to acknowledge and resolve clinical appeals. The Specialist maintains secure and efficient processes for regulatory record keeping of related documents and correspondence with consideration for potential reporting needs in support of these requirements, with the ability to produce all required documents for audits and regulatory review. Evaluates all clinical appeals for trend purposes, and reports findings to management. Establishes and maintains collaborative and meaningful interdepartmental relationships within the organization.
    • This position will support all lines of business for the organization.
    • This position may also support complaints and grievances processes in addition to clinical appeals.


    • Review and evaluate all clinical appeals submitted to the company while adhering to established timelines and initiate electronic tracking and distribution to the appropriate department for resolution.
    • Interprets and explains the company’s benefits, policies and procedures to members and providers as they relate to clinical appeals.
    • Communicate with members/providers as necessary to provide updates or obtain additional information needed for clinical decision making
    • Research, review, and facilitate detailed and compliant documentation of member benefits, authorization policy criteria, benefits or coverage information, etc, in accordance with the department’s clinical appeal policies and procedures for all Medicaid, Medicare and Commercial clinical appeals
    • Identifying potential quality issues and refer to the Quality Assurance Committee for investigations
    • Monitors assigned cases to ensure that resolution meets state and federally mandated timelines
    • Responsible for assisting the GAU Manager and the delegated GAU Reporting Analyst with generating reports, and other documentation
    • Utilize and evaluate trend data for reporting and to suggest action plans for quality improvement initiatives
    • Document final resolutions in the system of record along with all required data to facilitate accurate clinical appeals reporting for all Medicaid, Medicare and Commercial clinical appeals
    • Ensure final resolution letters are compliant and generated within the required timelines
    • Quality checks their own member and provider facing letters and when appropriate obtains legal opinion on language
    • Builds effective and successful interdepartmental relationships with all areas of the company and utilizes good communication and customer service skills in responding to internal and external inquiries about the clinical appeals process while being able to respond quickly regarding the status.
    • Collaborate with the designated GAU Reporting Analyst and GAU Manager to generate required reports on a pre-determined or ad hoc basis, including but not limited to CMS, EOHHS, OHIC and requirements and other reports as needed for analysis and trending
    • Collaborate with the designated GAU Reporting Analyst and GAU Manager to generate reports for including but not limited to CMS, EOHHS, OHIC audits, and participates in the compiling of all grievance, appeal, and complaint records selected for on-site audits
    • Collaborate with the Legal Department, GAU Manager and other departments to respond to, facilitate and monitor Administrative Law Judge (ALJ) and State Fair Hearings
    • Provide training to new team members as needed
    • Maintaining absolute file integrity with regards to content, location and confidentiality
    • Other duties as assigned
    • Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood’s Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and  the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents



    • Registered Nurse (RN) with an active, current, unrestricted license in Rhode Island in good standing
    • Minimum four (4) years’ relevant clinical experience with general nursing exposure to Utilization Management to include pre-authorization, utilization review, concurrent review, discharge planning, Case Management w/review, and/or skilled nursing facility reviews.
    • Minimum two (2) years of experience in a Grievances and Appeals OR Case Management-related setting


    • Intermediate Ability to create, review, and interpret treatment plans.
    • Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions.
    • Intermediate Knowledge of medical terminology and/or experience with CPT and ICD-9/10 coding.
    • Intermediate Knowledge of community, state and federal laws and resources.
    • Intermediate Knowledge of CMS regulations and Medicare Rules.

    Licenses and Certifications:

    • Candidate will be a Registered Nurse (RN)
    • Ideal candidate will have additional licenses or certifications                                

    Technical Skills:

    • Required Intermediate Microsoft Excel Proficient in Microsoft Outlook applications, including Word, Excel, Power Point and Outlook
    • Required Intermediate Microsoft Outlook
    • Required Intermediate Microsoft Word
    • Required Beginner Microsoft PowerPoint
    • Required Intermediate Experience with general Healthcare Management Systems
    • Ability to use proprietary healthcare management system


    • Seven (7) years’ relevant experience
    • Experience in a Grievances and Appeals Unit or Department
    • BSN Degree or Certification as a Case Manager
    • One (1) to two (2) years’ experience in an acute care clinical setting (Medical and/or Behavioral Health).
    • Two (2) years’ experience in Managed care experience with significant experience working in a setting like an inpatient hospital or partial hospital, Residential BH or Substance Use Disorder services, Community Mental Health Organization or other relevant facility or program.

    Organizational Competencies:

    • Judgment and Decision Making
    • Gets Results
    • Collaboration and Teamwork
    • Business Awareness
    • Customer Focus

    Job Specific Competencies:

    • Attention to Detail
    • Resilience
    • Influencing & Negotiation
    • Planning & Organizing
    • Problem Solving & Analysis

     FDR Oversight:

    • Minimal


    Neighborhood is an Affirmative Action and Equal Opportunity Employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, national origin, genetic information, age, disability, veteran status or any other legally protected basis.


    Neighborhood is committed to ensuring individuals with disabilities and/or those who have special needs participate in the workforce and are afforded equal opportunity to apply for jobs. If you would like to contact us regarding the accessibility of our Website or need assistance completing the application process, please contact us at recruiting@nhpri.org


    Neighborhood is an EOE M/F/D/V and an E-Verify Employer


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