The Appeals and Grievances manager is responsible for capturing and resolving all appeals/complaints/grievances for members in the Medicaid, Medicare, or other lines of business within the timeframes outlined by federal and state regulations.
* Research appeals or grievances that initiate from a variety of sources, including members, providers, state/federal regulators, and others within the timeframes outlined by federal and state regulations.
* Gather comprehensive documentation from varied internal and external sources relevant to issue raised in grievance/appeal. Ensure departments are responding to inquires in a timely fashion. * Prepare information releases, as appropriate in relationship to grievances/appeals, consistent with HIPAA regulations and company protocol. * Use critical thinking to investigate and correctly categorize cases and determine a course of review action and parties to contact. Accurately identify the different type of complaints. Prepare quality of care issues for further medical review. * Present analysis and documentation for non-clinical appeal reviews. * Document and maintain accurate grievance/appeal records in the designated databases with attention to detail. Modify authorizations as appropriate, and follow-up on resolutions as needed. Ensure all payments related to modifications in authorizations are issued. * Process correspondence to appealing party, timely and in accordance with federal/state regulations and established policies for all lines of business. * Work independently under time pressure, and maintain company compliance by resolving and closing grievances/appeals within the timelines established by regulatory agencies and the plan, according to the processes established by the plan. Exemplify the team value of the plan by assisting others as needed, to maintain compliance and organization standards. * Prepare case files for Quality Improvement Organization and Independent Review Entity levels when required. * Prepare case files for administrative law hearings, when required. * Provide superior customer service to internal staff, members, and providers in answering inquiries, gathering complaint information, or providing education. Understand and respect the cultural diversity of members. * Assist members when filing appeals; educate members, ensure proper documentation and flow of information, including appropriate escalation when applicable. * Manage the process for acknowledging, researching, and responding to complaints, grievances, and appeals that are received by the health plan from providers, members, and regulatory agencies. * Provide analysis to identify trends and assist with discovering root cause. * Compile monthly reports to track complaint response according to regulatory standards. * Update and maintain policies, procedures, and letters according to regulatory standards. * Collaborate with and maintain open communication with all departments within CHRISTUS to ensure effective and efficient workflow and facilitate completion of task/goals. * Determine trends within grievance and appeal issues that affect member satisfaction, member retention and recruitment, and work with the management team and appropriate staff to correct ongoing issues. * Maintain complete letter library, submit new letters for approval as required, based upon internal or regulatory changes.
Compliance: * Active participant in health plan accreditation. Maintains current knowledge with regards to regulatory standards and ensure compliance within scope of responsibility * Responsible for being compliant with rules and regulations in day to day activities in regards to or as dictated by legal, the Texas Department of Insurance, the Texas Health and Human Services Commission, the New Mexico Superintendent of Insurance, the Centers for Medicare and Medicaid, the Department of Defense, URAC, NCQA, and CHRISTUS Integrity which can include, but is not limited to, interactions with members and providers and following and adhering to departmental as well as organizational policies and procedures
Departmental: * Maintain departmental process, policies and/or procedures. Ensure departmental compliance of established processes, policies and/or procedures * Effectively determine/communicate/resolve all stakeholder concerns regarding the member experience * Collaborate and maintain open communication with all departments within CHRISTUS Health to ensure effective and efficient workflow and facilitate completion of tasks/goals * Follow CHRISTUS guidelines related to the Health Insurance Portability and Accountability Act (HIPAA) designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI) * Assume Leadership role in strategic projects for CHRISTUS Health Plans * Coach/mentor other associates within the team and serves as a resource person for the department. * Other duties as assigned
Ability to interpret and implement federal and state guidelines
Analytics ability to organize and prioritize work to meet deadlines
Knowledge of managed care products, benefits, and contracts
Good judgment, initiative, and problem-solving abilities
Ability to handle and resolve complex issues with little assistance
Excellent communication skills both verbal and written
5 years of experience in advocacy, Medicare experience preferred
History of progressively increasing responsibility/decision-making ability
Excellent written and oral communication skills, analytical and problems-solving skills, and interpersonal and teaming skills
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.