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Years of Experience
Date Last Verified
ProfileGrievance And Appeals Administrator (Manager) Duties: Responsible for oversight of the full grievances and appeals process health care firm members. Ensures compliance with member rights including notices and decisions as required by law and policy. Manages, oversees, implements and administers all aspects of the grievance and appeals system processes consistent with requirements for members, subcontractors and providers. Processes grievances and appeals for members and providers in accordance with guidelines in a timely, accurate manner consistent with law and Contract requirements and terms. Investigates and processes grievances and appeals in accordance with administrative regulations and state requirements including coordination with clinical and legal staff and providers. Prepares legal memoranda regarding decisions and represents at state fair hearings regarding decisions, Title XIX, and claims appeals. Reviews, analyzes, compiles data, recommends and reports on individual and agency providers to the Chief Executive Officer, the Chief Medical Officer, the Integrated Leadership Quality Council, the Integrated Quality Management Committee, the Integrated Provider Advisory Committee, Quality Management Department. Reviews analysis and data compilation as it applies to individual grievances and, monitors trends over time. Reviews and revises policies and procedures in collaboration with Executive Leadership and to ensure accurate and consistent application of requirements. Provides technical assistance and/or training to providers and staff regarding grievances, appeals, and Notice of Action processes in accordance with requirements. Participates on Quality Management Committee and other committees and workgroups as needed. May supervise employees including establishing performance goals, conducting performance appraisals, monitoring work and performing discipline as needed. Performs other duties of a similar nature and level as assigned.
Qualification and Experience
Qualifications: A JD Degree from an accredited institution with experience in behavioral health investigations and mediations/alternative dispute resolution. must have the ability to obtain Council on Licensure, Enforcement and Regulation (CLEAR) certification. Knowledge of laws, rules, regulations, policies, and legal practices related to health and behavioral health, and managed care, Knowledgeable of and maintain compliance with contract requirements as related to the job responsibilities outlined within the job description. Excellent Written and Oral Communication Skills. High proficiency with MSWord applications.
Job Reference #: 1703677