POSITION SUMMARY
Supports the Appeals Manager in the gathering of information to resolve customer concerns presented as a grievance or appeal. Works closely with internal departments and providers' staff to obtain pertinent information in a timely manner and in compliance with regulatory requirements.
COMPLIANCE WITH REGULATIONS
Works closely with all departments necessary to ensure that the processes, programs and services are accomplished in a timely and efficient manner in accordance with CHG policies and procedures and in compliance with applicable state and federal regulations including Centers for Medicare and Medicaid Services (CMS) and/or Medicare Part D, Department of Managed Health Care (DMHC) and Department of Health Care Services (DHCS).
RESPONSIBILITIES
- Educates and assists members and their family members or authorized representatives of Medicare and Medi-Cal grievance and appeals rights.
- Determines member eligibility and utilization history using QNXT's membership, claims, prior authorization, and case management, complaint tracking systems.
- Prepares and mails resolution decision letters that meet Medi-Cal or Medicare (CMC) requirements for content and timeliness.
- Determines additional levels of appeals that member is entitled to and processes them in accordance with Medi-Cal and Medicare standards and requirements for timeliness.
- Analyzes data collected and coordinates with member's treating providers and pertinent departments to resolve member's grievance.
- Collects, analyzes and interprets data collected and communicates results in person or in writing to Grievance and Appeals Manager.
- Responsible for reviewing, classifying, researching, investigating and resolving member complaints (grievances and/or appeals).
- Within established timeframes, communicates resolution to members or their authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid.
- Adheres to CHG's Appeals and Grievances policies are based on Medicare Managed Care Manual Chapter 13 and Title 22, pertaining to the processing of Medicare grievances and appeals.
- Responsible for addressing and forwarding quality of care complaints to quality management for resolution.
- Responsible for documenting on a daily basis all cases in Innovare.
- Participate in regular meetings to review case logs and other matters as assigned.
- Responsible for compiling, preparing and reporting all compliance and grievance data monthly.
- Responsible for formulating/implementing and executing all processes, requests, workflow or policies as requested by management in a courteous and efficient manner, including offering a proactive approach to suggestions and recommendations and working or cooperating with Appeals and Grievance Manager or management effectively.
- Act as a liaison to all company departments as necessary.
- Responsible for special assignments or projects as requested by management.