• Grievance and Appeals Clinical Specialist

    Job Locations US-RI-Smithfield
    Req No.
    2018-8713
    Department
    Grievance And Appeals
    Type
    Regular Full-Time
    Category
    Grievance And Appeals
  • Overview

    As it relates to clinical appeals and quality of care complaints and grievances and strict state and federal deadlines, is responsible for research, review and facilitation of Medicaid and Medicare processes. Coordination of effort may involve coordinating multiple programs and commercial insurance. Establishes and maintains cohesive and successful interdepartmental relationships within the organization and with external customers. Responsible for interpreting and accurately documenting determinations. Monitors assigned cases and trends while ensuring that resolution meets state and federally mandated timelines. Utilizes and evaluate trend data for reporting and to suggest action plans for quality improvement initiatives and coordinate audits.

    Responsibilities

    • Review and evaluate all clinical appeals and quality of care complaints and grievances submitted via the CMS Complaint Tracking Module (CTM) while adhering to established timelines
    • Research, review and facilitate documentation of Medicare/Medicaid benefits, policies and procedures as it relates to the department’s grievance and appeals function
    • Identifying potential quality issues and initiate investigations
    • Interprets and communicate Medicaid/Medicare benefits, policies and procedures with internal and external customers  
    • Responsible for generating reports, documentation and correspondence and accurately documenting determinations
    • Document final resolutions along with all required data to facilitate accurate reporting
    • Act as a clinical resource for internal and external customers on status and inquires of process
    • Generate required reports on a pre-determined or ad hoc basis, including but not limited to DOH and DHS and CMS requirements and other reports as needed for analysis and trending
    • Utilizes and evaluate trend data for reporting and to suggest action plans for quality improvement initiatives and coordinate audits.
    • Monitors assigned cases and trends while ensuring that resolution meets state and federally mandated timelines
    • Compile and produce reports for NCQA, DHS, CMS audits for audit purposes
    • Maintains secure and efficient processes for regulatory record keeping of related documents, correspondence and reporting needs that support these requirements and organize appropriately for audits and regulatory review
    • Referring substantiated quality of care issues to appropriate departments
    • Maintaining absolute file integrity with regards to content, location and confidentiality
    • Preparing for and participating in regulatory site visits
    • 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

    Qualifications

    Required:

    • Registered Nurse with an active, current, unrestricted license in Rhode Island in good standing
    • BSN Degree or Certification as a Case Manager
    • Three (3)+ years’ clinical experience in a clinical setting
    • Good working knowledge of regulatory requirements/standards
    • Strong organizational and documentation skills
    • Excellent customer service orientation and interpersonal skills
    • Strong communication skills (written/verbal)
    • Intermediate to Advanced skills in Microsoft Office (Word, Excel, Outlook)
    • Demonstrated ability to effectively prioritize and execute tasks in a high-pressure environment and meet contractual timelines
    • Strong analytical skills
    • Demonstrated ability to excel in a team environment as well as independently

    Preferred:

    • Chart review experience
    • Utilization management experience
    • Appeals experience
    • Medicaid/Medicare regulations and reporting requirements experience
    • Bilingual (Spanish)

    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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