► CareersGrievance and Appeals Specialist

Grievance and Appeals Specialist

This position participates in all aspects of the grievances, appeals and inquiry process at Minuteman Health, with the specific goals of promoting consistency and accuracy and to maintain NCQA, URAC, general accreditation, regulatory compliance, and to ensure adherence to all HIPAA guidelines.

Responsibilities:

  • Participate in all aspects of the member and provider grievance, complaints and appeals casework process including:
    • Log and independently review all receipts and apply various regulations to appropriately classify all incoming cases in tracking database,
    • Issue acknowledgement letters within required timeframes,
    • Independently 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,
    • Triage cases for input from other Minuteman and external stakeholders as applicable and ensure all timeframes are met,
    • Prepare written response and determination letters that appropriately address the issue and that meet all regulatory and NCQA requirements within required timeframes.‚Äč
  • Communicate with members and providers verbally and in writing.
  • Ensure grievance, complaint and appeal files are well-organized, complete and meet all NCQA and internal requirements. Participate in file audits as needed.
  • Participate in the analysis of grievance, complaints and appeals data and the preparation of narratives, graphs and flowcharts to be utilized for committee presentations, audits, and any internal/external reports.
  • Produce routine and adhoc reports on grievances, complaints and appeals from the grievance and appeals database.

Qualifications:
  • Bachelor’s degree or equivalent
  • Minimum of one year of experience in member and/or provider grievance, complaints and appeals work.
  • Minimum of two years of experience working in claims, enrollment, billing or member services in a health insurance plan setting.
  • Excellent verbal, written and interpersonal communications skills, with the ability to write complex letters and reports and make effective verbal presentations.
  • Ability to manage multiple projects and deadlines simultaneously
  • Sound judgment and decision making abilities. Ability to process complex information quickly and thoroughly.
  • Computer skills including working knowledge of Microsoft Word, Excel, and Access; familiarity with PowerPoint desired

Description of Company:
 

Minuteman Health is a new non-profit health insurance option for Massachusetts and New Hampshire residents. Founded by contributors that include Tufts Medical Center, Vanguard Health Systems and New England Quality Care Alliance (NEQCA), Minuteman offers consumers and employers lower-cost high-quality care with unprecedented transparency, as well as increased efficiency and satisfaction for physicians, patients, and employers alike.


*Please, NO recruiters or agencies


 


 



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