The role is responsible for logging, tracking, and processing appeals, grievances, and incidents. The Specialist responds to written/verbal grievances, complaints, appeals, and disputes submitted by members and providers in accordance with NCQA, CMS, NY State, and other regulations. Types of correspondence handled by the individual will include, but are not limited to, correspondence, payment disputes, complaints/grievances, and appeals. Work requires exercising considerable independent judgment and initiative in performing case file investigation.
• As the department liaison by coordinating various departments to ensure grievances/incidents are processed timely and compliance requirements are maintained.
• Identify root cause or errors and develop resolutions plans, ensure prompt resolution of case reviews and issues.
• Process all levels of member and provider grievances/incidents, including assisting with escalated grievances/incidents (state/federal level).
• Receive, document, investigate, refer, resolve, and coordinate grievances/incidents/appeals.
• Initiate case files for each grievance/incident/appeal and ensure compliance with organizational and regulatory requirements.
• Ensure regulatory compliance, stringent timeframe requirements and accuracy standards are met.
• Develop correspondence communicating the outcome of grievances/ nonclinical incidents and appeals to enrollees and/or providers.
• Coordinate efficient functioning of day-to-day operations according to defined processes and procedures.
• Create and maintain accurate records documenting the actions and rationale for each grievance/incident or appeal decision.
• Complete and coordinate department audits and quality projects as assigned.
• Performs other duties as assigned or required.