We are currently hiring a TEMPORARY Grievance System Specialist! If you are a detail-oriented professional, effective communicator, thrive in a fast-paced, deadline-driven environment, and value being part of a team that makes a difference, you may be the right person for the position! Apply today!
Classification: NON-EXEMPT | Status & Schedule: FULL-TIME, TEMPORARY (approximately 4 - 6 months), MONDAY – FRIDAY, 8AM – 5PM
Location: REMOTE, must reside in approved list of states (OR, CA, AZ, TX, FL)
Salary: $22.50 - $29.24/HOURLY
Department: GRIEVANCE & APPEALS | Reports to: CHIEF COMPLIANCE & QUALITY OFFICER | Supervision Exercised: NON-SUPERVISORY Job Purpose: Grievance System Support
This position is responsible for supporting the overall operations of the Coordinated Care Organization (CCO) Member Grievance System. This position processes member grievances and appeals from the initial receipt to resolution or denial within the required timelines, and federal, and state guidelines, while maintaining clear and timely communication to members, providers, CCO employees, and other stakeholders.
Qualifications, Education, & Experience - Minimum High School Diploma or GED; associate or bachelor’s degree in business or healthcare administration preferred, experience in lieu of degree will be considered
- Minimum one to two years’ experience in managed care or other healthcare setting
- One to two years’ experience investigative, reporting, or information analysis strongly preferred
- THW Certification preferred, or willing to obtain - Must reside in Oregon
- Bilingual preferred, qualified, certified, or willing to obtain
Essential Responsibilities: Grievance System Support - Responsible for creating and maintaining positive relationships between organization, Advanced Health members, delegates, and providers
- Assist and support the Member Grievance System life cycle, including the coordination of denials, grievances, appeals, and hearings
- Utilize internal and external systems to conduct comprehensive investigations, including collecting and reviewing information from members, providers, and delegates, verification of eligibility, authorizations, claims processing, plan coverage information, and any other information relevant to issues raised in the grievance/appeal; prepare cases for physician review
- Maintain working knowledge of applicable OAR’s, OHA guidelines, Oregon Health Plan (OHP) benefits, and Advanced Health programs
- Work closely with internal staff and Advanced Health’s delegated partners to ensure that procedures are followed for handling and tracking notices of adverse benefit determination, grievances, appeals, and hearings
- Ensure the appropriate and applicable information release forms are signed and on file
- Document and maintain accurate member grievance system records with attention to detail
- Ensure correspondence with all parties is timely and complete in accordance with federal and state regulations and established policies and procedures
- Maintain compliance by resolving and closing grievances and appeals within the timelines established by regulatory agencies and Advanced Health, according to processes established by Advanced Health
- Prepare files for administrative hearings and audits both internally and by outside entities (such as an External Quality Review Organization)
- Monitor for grievances and appeals related to second opinion requests, billing issues, discrimination or retaliation, and other potential concerns related to members’ rights
- Educate members and providers about the member’s grievance system rights and processes to follow
- Assist members with accessing and completing the grievance and appeal processes, including help with completing forms and ensuring translation services are available as needed.
- Provide regular reports to the Executive Team, and others as requested regarding grievance activity, trends, and offer suggestions for improvement
- Participate in quality and organizational process improvement activities and teams when requested
- Ensure compliance with company policies and procedures as applicable to area(s) of responsibility
- Handle confidential information and materials appropriately and maintain a secure work area
- Other duties as assigned
Essential Responsibilities: ORGANIZATIONAL TEAM MEMBER - Participate in quality and organizational process improvement activities when requested
- Support and contribute to effective safety, quality, and risk management efforts by adhering to established policies and procedures, maintaining a safe environment, promoting accident prevention, and identifying and reporting potential liabilities
- Openly, clearly, and respectfully share and receive information, opinions, concerns, and feedback in a supportive manner
- Work collaboratively by mentoring new and existing co-workers, building bridges, and creating rapport with team members across the organization
- Provide excellent customer service to all internal and external customers, which includes team members, members, students, visitors, and vendors, by consistently exceeding the customer’s expectations
- Recognize new developments and remain current in care management and coordination best practice standards and anticipate organizational modifications
- Advance personal knowledge base by pursuing continuing education to enhance professional competence
- Promote individual and organizational integrity by exhibiting ethical behavior to maintain high standards
- Represent organization at meetings and conferences as applicable
Knowledge, Skills, & Abilities: - Understanding of Oregon State grievance, appeals, and administrative hearings rules and regulations
- Understanding of Oregon Health Plan program requirements, benefit package, eligibility categories, and Oregon Health Services Division rules and regulations
- Knowledge of Medicare parts A and B benefit packages and the Centers for Medicare and Medicaid Services (CMS) rules and regulations
- Knowledge of managed care concepts, principles, and operations
- Knowledge of administrative and clerical procedures
- Critical attention to detail for accuracy and timeliness
- Ability to report to work as scheduled, and willingness to work a flexible schedule when needed
- Proficient in Microsoft Office Suite and Windows Operating System (OS)
- Training in or awareness of Health Literacy, Poverty Informed, Systemic Oppression, language access and the use of healthcare interpreters, uses of data to drive health equity, Cultural Awareness, Trauma-Informed Care, Adverse Childhood Experiences (ACEs), Culturally and Linguistically Appropriate Service (CLAS) Standards, and universal access
- Knowledge and understanding of how the positions’ responsibilities contribute to the department and company goals and mission
- Knowledge of federal and state laws including OSHA, HIPAA, Waste Fraud and Abuse
- Awareness and understanding of equity, diversity, inclusion, and the equity lens: ability to analyze the unfair benefits and/or burdens within a society or population by understanding the social, political, and environmental contexts of policies, programs, and practices
- Excellent people skills and friendly demeanor
- Critical thinking skills of using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems
- Attention to detail and organization skills
- Ability to handle stress and sensitive situations effectively while projecting a professional attitude
- Ability to communicate professionally, both conversing and written
- Ability to work with diverse populations and interact with people of differing personalities and backgrounds
- Sensitive to economic considerations, human needs and aware of how one’s actions may affect others
- Ability to organize and work in a sensitive manner with people from other cultures
- Poised; maintains composure and sense of purpose
Working Conditions:
This position must have the ability to remain in a stationary position, occasionally move about inside the office to access office machinery, printer, etc., frequently communicate and exchange accurate information. Work Condition: Remote- Employee generally works within a remote work from home environment.
- Travel may be required on occasion.
- Hours of operations and specific staff scheduling may vary based on operational need.
Exposed to:- Employee is responsible for maintaining a safe work environment that is conducive to successful productivity and work output.
- Machines, equipment, tools, and supplies used: Constantly operates a computer or other office productivity machinery or software, such as fax, copier, calculator, multi-line telephone system, or scanner.
- May answer a high volume of telephone calls, complete documentation, and use computer programs to either obtain or record information.
- Multiple Duties: Must be able to work under conditions of frequent interruption and be able to stay on task.
Other Information:
This job description is intended to provide only basic guidelines for meeting job requirements. This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of DOCS Management Services employees. Other duties, responsibilities and activities may change or be assigned at any
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