Grievance and Appeals Specialist

Temporary Full Time Grievance and Appeals Specialist
South Country Health Alliance

South Country Health Alliance is seeking a temporary Grievance and Appeals Specialist to join our team! This role is responsible for the management of assigned caseload involving member complaints received at South Country Health Alliance (SCHA) which may include member grievances or appeals. This department performs advanced and complicated case review duties requiring clinical judgment independent analysis and detailed knowledge of departmental and regulatory procedures.

What Youll Bring:

• 2 years Health plan experience and/or experience conducting complaint investigations;
• Proficiency in Microsoft Office especially Word and Excel
• Familiarity with medical terminology
• A knowledge of both State Public Programs (MN Medicaid) and Medicare (dual) products
• A valid unrestricted LPN License/ RN License is preferred

Why South Country

South Country Health Alliance is more than a health planwere a mission-driven organization dedicated to improving health and well-being in rural Minnesota communities. Our work is guided by values of communication collaboration stewardship and excellence ensuring that every employee contributes to making a real difference in peoples lives.

Join us and be part of an organization that values community impact employee well-being and innovation.

Temporary positions with South Country Health Alliance are not benefit eligible. This position is a hybrid position- requiring in office time in Medford MN as organizationally necessary. This position could run up to 6 months.

Salary for this position starts at $30-$50/hour based on qualifications and experience.

Must be legally authorized to work in the U.S. (No sponsorship available)

POSITION DESCRIPTION (NON-EXEMPT)

Position Title: Temporary Grievance & Appeals Specialist

Dept: Grievance and Appeals

Reports To: Grievance & Appeals Manager

Skill Set: Follows direction and completes assigned job tasks independently; Performs job duties within his/her scope of practice; Accurately categorizes requests and issues proper notices; Demonstrates excellent written and verbal communication skills; Ability to work cross departmentally and effectively with business partners including Third Party Administrators (TPAs) health care providers and professionals; Ability to multi-task prioritize assigned tasks and work effectively under pressure

Education/Experience: Preferred: Current valid and unrestricted Minnesota LPN License and at least 2 years of health care experience. An equivalent combination of applicable education professional training and health care experience which demonstrates the ability to successfully perform the responsibilities of this job may be considered in lieu of a degree; Proficient in Microsoft Office especially Word and Excel; Familiar with medical terminology. Health plan experience and/or experience conducting complaint investigations; Associate Degree Nurse with active unrestricted Minnesota license also preferred.

Primary Function

The Grievance and Appeals Department is responsible for the management of assigned caseload involving member complaints received at South Country Health Alliance (SCHA) which may include member grievances or appeals. This department performs advanced and complicated case review duties requiring clinical judgment independent analysis and detailed knowledge of departmental and regulatory procedures.

Essential Responsibilities:

1. Processes member complaints and related requests thoroughly and completely by acquiring appropriate records and/or other information and applying problem-solving skills and investigative methodology. Cases will be processed in accordance with regulatory requirements and departmental policies and procedures ensuring timely and proper resolution. Accurately interprets and applies policy and regulation.
2. Contacts others as necessary to obtain case related information which may involve obtaining the assistance of other SCHA staff for review/investigation of information; will collaborate effectively with others including but not limited to SCHAs Chief Medical Officer and/or Medical Director SCHAs Health Services Member Services and Operations departments county staff delegated entities and providers.
3. Maintains accurate and complete case documentation which includes both electronic and hard copy case files. Ensures related correspondence is scanned into the electronic record.
4. Assist the G/A team with administrative functions which may include but is not limited to returning phone calls faxing correspondence scanning and uploading documents mailing letters and preparing case files.
5. Conducts necessary and appropriate case preparation interviews and record review. Collects information from a variety of sources including members providers and SCHA staff.
6. Collects and compiles G/A data as directed on a daily monthly or quarterly basis.
7. Updates G/A tracking tools department spreadsheets and other documents as necessary.
8. Professionally and accurately drafts correspondence as assigned.
9. Assists with last minute urgent requests which may include preparing case files for external reviewers.
10. Performs other job duties as assigned within the scope responsibility and requirements of the job.

Additional Requirements:

To perform this job successfully an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge skill and/or ability required.

Language Skills:

Must be able to read and write in English; must communicate in an accurate clear and concise manner.

Mathematical Skills:

Basic Mathematical skills required.

Accuracy:

The impact of errors or negligence may involve a significant financial loss if an incorrect benefit or clinical appeal decision is made. Errors could also significantly affect enrollees ability to access services.

Reasoning Ability:

Must understand cause and effect relationships and be able to draw conclusions from data regulatory requirements and past practice.

Physical demands:

The physical demands described represent those that must be met by an employee to successfully perform the essential functions of this job. Where possible reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job the employee is regularly required to talk or hear. The employee frequently is required to sit. The employee is occasionally required to stand; walk; use hands to navigate office equipment (i.e. computer telephone etc.) office supplies and reach with hands and arms.

The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision distance vision peripheral vision depth perception and the ability to adjust focus.

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job the employee should encounter no unusual or hazardous conditions. The noise level in the work environment is usually low.

Travel Requirements:

Limited exposure to long distance travel except on rare occasions.

Contacts:

This position works most closely with Member Services Health Services and Operations departments and externally with providers such as physician clinics and hospitals; maintains satisfactory relationships; may include collaboration in executing established policies discussion of ways to reach agreed-upon objectives and securing compliance with approved procedures.

Financial Impact:

This position is responsible for ensuring that SCHA is following contractual language as promulgated by governmental agencies. Failure to comply with this contractual language could result in breach of contract resulting in a significant financial penalty potential contract cancellation sanctions and/or corrective action.