This position is responsible for adhering to the contractual requirements for state and federal government reporting and regulations in support of the Grievance and Appeals System, including grievances, Notice of Adverse Benefit Determination (NOABD) requirements, appeals, contested case hearings, reconsiderations, continuation of benefits, implementation of reversed appeal resolution, record keeping, and quality improvement. This position is also responsible for maintaining compliance with policies, procedures, and contractual requirements as they relate to the Grievance and Appeals System by performing the following duties.
- Maintains compliance with policies and procedures, contractual requirements, and state and federal regulations in support of the Grievance and Appeals System.
- Provides written acknowledgment of all member and provider correspondence, including coordinating requests to release information on member’s behalf.
- Assists in maintaining policies, procedures, workflows, and forms for the Grievance and Appeals System and keeps them stored in approved location.
- Documents and updates Grievance and Appeals related data systems and platforms for tracking, reporting, and monitoring of appeals, grievances, reconsiderations, and NOABDs.
- Investigates and resolves grievances, collects appropriate documentation to process appeals and hearings, details and tracks applicable information as it moves through the process.
- Maintains detailed interactions with members which includes contacting the member and/or provider to collect information and communicate final disposition of the case.
- Independently reviews requests of cases received; interprets regulations and appropriately classifies the inquiry.
- Makes critical decisions regarding research and investigation to appropriately categorize and resolve all inquiries and escalates to Grievance & Appeals Manager as necessary.
- Independently conducts thorough investigations of all member and provider correspondence by analyzing all the issues involved and obtaining responses and information from internal and external entities.
- Assists with completion of reporting to OHA, internal leadership and committees.
- Identifies trends of high-risk and high-needs cases and reports to supervisor.
- Prepares written responses to all members and providers that appropriately addresses each complainant's issues and are structurally accurate.
- Completes necessary documentation and research for appeals, reconsiderations, hearings, and grievances electronically through designated systems.
- Assists with development and presentation of provider training relating to Grievance and Appeal System.
- Identifies and engages with clinical resources, as necessary, using sound, fact-based decision-making skills to render a decision for non-clinical complaints.
- Stays current with regulatory requirements through review of periodicals, Oregon Administrative Rules, compliance association newsletters and review of state and federal regulatory agency web sites, publications, and contracts.
- Maintains confidentiality and complies with HIPAA rules and regulations.
- Maintains punctual, regular, and predictable attendance.
- Works collaboratively in a team environment with a spirit of cooperation.
- Displays excellent communication skills including presentation, persuasion, and negotiation skills required in working withmembers and coworkers, including the ability to communicate effectively and remain calm and courteous under pressure.
- Respectfully takes direction from manager.
EDUCATION and/or EXPERIENCE
Bachelor’s Degree from four-year college or university and two to four years related experience and/or training; or equivalent combination of education and experience.
COMPUTER SKILLS
Job requires specialized computer skills. Must be adept at using various applications including database, spreadsheet, report writing, project management, graphics, word processing, presentation creation/editing, communicate by e-mail and use scheduling software.
We provide a competitive salary and excellent benefits, including vacation, medical, dental and vision insurance, and 401(k) pension plan. To apply for this position, please submit a cover letter and resume. We are an Equal Opportunity Employer.
Job Type: Full-time
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Disability insurance
- Employee assistance program
- Flexible spending account
- Health insurance
- Life insurance
- Paid time off
- Professional development assistance
- Retirement plan
- Tuition reimbursement
- Vision insurance
Schedule:
- 8 hour shift
- Monday to Friday
Work setting:
Ability to Relocate:
- Klamath Falls, OR 97601: Relocate before starting work (Required)
Work Location: Hybrid remote in Klamath Falls, OR 97601