The Grievance and Appeals Clinical BH Specialist (Specialist) will be primarily responsible for performing a preliminary review and preparing BH-related clinical appeals for physician review for Neighborhood’s Medicare-Medicaid Population (MMP). The Specialist will also be responsible for handling BH-related informal complaints and formal grievances for Neighborhood’s Exchange and Medicaid Lines of Business. The Specialist will handle, review, and ensure compliance with all BH-related appeal and complaint/grievance activities. The Specialist will handle these appeals and complaints/grievances in accordance with Neighborhood Policies & Procedures in an efficient and timely manner within required timeframes and in accordance with CMS, EOHHS, NCQA, and other applicable regulatory requirements. The Specialist will perform appeal reviews using medical and/or behavioral health records in conjunction with established clinical guidelines and member benefit plans. The Specialist will communicate the outcome of the appeals or complaint/grievance process with Neighborhood members, a member’s authorized representative, and/or provider, as well as any internal and external partners, as needed/required.
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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.
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Neighborhood is an EOE M/F/D/V and an E-Verify Employer