Grievance & Appeals Specialist

Summary of Job

Respond to written/verbal grievances, complaints, appeals and disputes submitted by members and providers in accordance with NCQA, CMS, State and other regulations. Process appeals and grievances to facilitate the accurate administration of benefits and clinical policy; ensure compliance of the appeal and grievance process with all regulatory requirements and NCQA standards. Work as an effective interface between internal and external customers. Maintain good member and provider relations

Responsibilities:

• Comprehensively review and evaluate appeal and grievance requests to identify and classify member and provider appeals.
• Determine eligibility, benefits, and prior activity related to the claims, payment or service in question.
• Provide written acknowledgment of member and provider correspondence.
• Responsible for making verbal contact with the member or authorized representative during the research process to further clarify, as needed, the member's complaint or appeal.
• Conduct thorough investigations of all member and provider correspondence by analyzing all the issues involved and obtaining responses and information from internal and external entities.
• Serve as liaison with EmblemHealth departments, delegated entities, medical groups and network physicians to ensure timely resolution of cases.
• Research appeal files for completeness and accuracy and investigate deficiencies. Consult with internal areas as required (such as the Legal Department) to clarify legal ramifications around complex appeals.
• Follow-up with responsible departments and delegated entities to ensure compliance.
• Accurately and completely prepare cases for medical and administrative review detailing the findings of their investigation for consideration in the plan's determination.
• Monitor daily and weekly pending reports and personal worklists, ensuring internal & regulatory timeframes are met.
• Responsible for monitoring the effectuation of all resolution/outcomes resulting from internal appeals as well as all appeals reviewed through the IRE.
• Identify areas of potential improvement and provide feedback and recommendations to management on issue resolution, quality improvement, network contracting, policies and procedures, administrative costs, cost saving opportunities, best practices, and performance issues.
• Prepare written responses to all member and provider correspondence that appropriately address each complainant's issues and are structurally accurate.
• Ensure documentation requirements are met: create and document service requests to track and resolve issues; document final resolutions along with all required data to facilitate accurate reporting, tracking and trending.
• Perform other duties as assigned or required.