Grievance and Appeals Specialist
Dean Health Service Company, LLC

Job Info

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It's more than a career, it's a calling.
WI-Dean Health Plan 1277 Deming

Worker Type:
Regular

Job Summary:
Research and respond to customer appeals and grievances as well as complaints filed through Employee Trust Funds (ETF), the Office of the Commissioner of Insurance (OCI), Office of Personnel Management (OPM), and reviews filed with Maximus/Center for Health Dispute Resolution (CHDR) and Independent Review Organizations (IROs) within the defined time standards of each. Interpret contracts and company guidelines, policies and procedures, NCQA guidelines, Wisconsin State Statutes, CMS and Federal guidelines. Administer the Quality Management Program and meeting/maintain department quality standards. Proactively identify issues and problems affecting quality and take ownership for resolution. Monitor completed processes and track them against state and federal regulation as well as internal policies and procedures.

Job Responsibilities and Requirements:

PRIMARY RESPONSIBILITIES

• Research each case thoroughly and prepare (when applicable) grievance packets for the Grievance and Appeal Committee members or quality packets for Medical Peer Review Committee, within defined due dates. Prepare draft responses to customer appeals, grievances, ETF complaints, OCI complaints, CHDR complaints and IROs within the required time frame of each. Maintain accurate and complete complaint, grievance/appeal and quality information in the department database and SharePoint in a timely manner.
• Coordinate all follow up and subsequent action needed as a result of case review (i.e., claims and/or authorization processing). Prepare and send appropriate files to ETF, OCI, Maximus/CHDR, and IROs to the appropriate entity within the required time standards.
• Ensure Quality of Care and Quality of Service issues are identified and documented.
• Perform intermediate and advanced level daily quality assurance reviews to ensure and report on the accuracy. Define and build test scenarios and test cases; execute tests and report test results; provide metrics for analysis and reporting to measure quality assurance effectiveness.
• Ensure errors discovered are corrected in a timely manner; verify the adjustment of claims and request system updates needed to avoid future occurrences. Measure performance and report audit results to management (monthly/quarterly/annual) and staff; coach staff on errors. Identify training and development trends, and take actions as needed to address trends in conjunction with department supervisors.
• Produce tools to assist processors, including desk aids, presentations, and on-line tools.
• Assist management in implementing and updating P&Ps as required.
• Interpret and understand state guidelines and regulations applicable to related insurance.
• Maintain physical and technical security and privacy of protected health information (PHI).
• Conduct projects and participate in team activities to identify problems and improve work processes and systems. Assist the management team in producing innovative solutions for identified problems (corporate-wide quality improvement).
• Performs other duties as assigned.

EDUCATION

• High school diploma or equivalent

EXPERIENCE

• Three years' customer experience

PHYSICAL REQUIREMENTS

• Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs.
• Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements.
• Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors.
• Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc.
• Frequent keyboard use/data entry.
• Occasional bending, stooping, kneeling, squatting, twisting and gripping.
• Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs.
• Rare climbing.

Work Shift:
Day Shift (United States of America)

Job Type:

Employee

Department:
97290188 700440-Member Relations and Customer Exp

Scheduled Weekly Hours:
40

SSM Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex.

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