Note The job is a remote job and is open to candidates in USA. reputed company is a company focused on quality management in healthcare, and they are seeking a Grievance and Appeals Analyst. This role involves responding to grievances and appeals, ensuring compliance with regulations, and analyzing data to identify trends and solutions. Responsibilities Responsible for receiving and monitoring information related to provider quality assurance issues including but not limited to grievances, quality of care concerns, and/or appeals Works to ensure comprehensive quality assurance information is available to agency staff/departments as needed Leverages critical thinking to identify trends within grievance, appeal, and other clinical data sources Creates actionable analysis and identifies the most effective party to address any identified issues with minimal supervision Works independently to mediate complex relationships between multiple external and internal stakeholder so that all parties are satisfied with identified resolutions Ensures resolutions of issues related to member experiences are compliant with local, state and federal regulations Utilizes various internal and external data platforms to perform a thorough analysis of issues related to member experiences Utilizes professional communication skills to provide information to internal and external stakeholders verbally and in writing Monitors timelines to ensure that quality assurance issues and reports are reviewed in a timely manner as to be most effective for agency processes Uses analytical skills to define recommendations and improve practices Creates and presents analyses of short-term studies using clear and direct language to explain trends and areas of opportunity to management and other staff; Trains internal and external customers on quality assurance reporting requirements Reviews policies and procedures and makes recommendations for changes/edits in alignment with current guidelines and requirements Collaborates with internal staff to ensure all relevant information is available for consideration Prepares and ensures timely mailing of receipt of appeal and outcome notification letter to the individuals/ guardians and providers based on the most current formats and timeline requirements Tracked appeal requests and assignment of the local reconsideration review process through resolution Maintains all denial and appeals reputed company in a an accessible manner Participates in the development of internal training on Denial and Appeals as determined by the internal and external quality reviews Aids legal counsel in ensuring fluent communication and exchange of documents are effectively made between all parties involved in the appeals process Ensures Alliance staff are prepared for mediation and hearings by preparing and organizing all legal and clinical documents for 2nd level appeals Assists in the discovery process with Alliance’s legal department and draft Office of Administrative Hearings (OAH) documents Schedules mediation hearings and documents the process and outcomes Provide training and technical assistance to staff regarding Due Process rules Reviews first level appeal decisions to ensure first level appeal reviewers are applying service definition and clinical guidelines when making appeal determinations Writes, edits, and/or coordinates the preparation of correspondence, reports, or other printed material according to well established standards or readily available Performs other related duties as assigned Skills A minimum of a Bachelor’s degree from accredited college or university with a major in mental health, public health, psychology, sociology, public administration, management information systems, statistics, or a related field A minimum of two years working human services/behavioral health post bachelor’s degree A minimum of two years of experience analyzing data sets, interpreting and synthesizing data into a report format, and working with teams/units to integrate data information needs Knowledge of Federal and State regulations on Behavioral Healthcare grievances and appeals processes Knowledge on medical records practices and records keeping practices Knowledge of legal proceedings including mediation, administrative law courts, and other legal processes Demonstrated proficiency in personal computer use and MS Excel Must have good oral, written, and graphic presentation skills Must demonstrate understanding of data analysis and techniques Demonstrated ability to learn new software and user capabilities Ability to integrate programmatic information into required data sets for analysis and interpretation Ability to work well with others in a fast-paced, and sometimes stressful, environment Experience with customer service, provider relations or similar activities Experience working with individuals with mental health, substance abuse issues, and/or intellectual disabilities Benefits Medical, Dental, Vision, Life, Long Term Disability Generous retirement savings plan Flexible work schedules including hybrid/remote options Paid time off including vacation, sick leave, holiday, management leave Dress flexibility Company Overview reputed company is the managed care organization for publicly funded behavioral healthcare services. It was founded in 2012, and is headquartered in Fayetteville, North reputed company, USA, with a reputed company of 1001-5000 employees. Its website is https//www.alliancehealthplan.org/. Apply To This Job
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