What are the responsibilities and job description for the Remote - Appeals & Grievances Specialist - Temporary position at Commonwealth Care Alliance?
- Processing of Grievances & Appeals.
- Responsible for the progress of grievance and appeal intervention and resolution.
- Assure verbal and written responses are provided to members and/or other parties within the required timeframes.
- Assure timely completion of member verbal and written correspondence.
- Thoroughly document all member appeal and grievance related interactions and interventions into CCA database.
- Member Outreach: Provide accurate, prompt, and courteous service in response to written and telephonic member complaints.
- Responsible for communication and member outreach related to the member complaint.
- Support creation, review, and mailing of notices to members to ensure prompt and courteous member communication and that the organization is compliant and meeting all strict deadlines.
- When necessary, collaborate with care teams, clinical staff, family members, and other involved in providing care for our members.
- Interdisciplinary Communication and Collaboration: Communicate and work collaboratively with CCA departments to help manage and resolve member appeals and grievances.
- CCA departments to help manage and resolve member appeals and grievances.
- Act as a liaison between multiple departments to ensure the timely and complete capture and processing of all grievances and appeals.
- Interdepartmental stakeholders include but are not limited to quality; regulatory affairs/compliance; clinical, operations, pharmacy, dental, reporting, and member services.
- Supports the Senior Appeals & Grievance Coordinator and A/G Coordinator in day-to-day tasks and assignments.
- Content Expert: Act as CCA’s content expert on State and Federal Grievance and Appeal regulations for all CCA products.
- Appropriately interpret, apply, and communicate CMS and State regulations. - Remain apprised of policy updates and update operational processes.
- Complaints Monitoring: Supports daily monitoring of Medicare and EOHHS Complaints Tracking & Management (CTM) Module and timely communication of next steps on complaints notification, intervention, and resolution. Secondary Qualifications
- Other duties and projects as appropriate and assigned.
- Supports and assist with process improvement activities to address complaint trends and enhance processes.
- Supports A/G team in identifying and analyzing complaint trends and presenting this data within CCA.
- Assist in the update of CCA’s Appeal and Grievance Policy and Procedures as well as related Standard Operating Procedures and workflows.
- Supports preparation of materials and data for internal and external audits of grievance and appeals processes as well as data validation activities, as needed.
- Supports the maintenance of updated data in Appeal/Grievance application of the member enrollment database system to ensure successful audit preparation; supports the review data for completeness and accuracy.
- 0-2 years. - Associate's Degree or equivalent experience.
- Must be a self-starter with a high degree of accountability and responsibility. –
- Commitment of the mission of the organization. –
- Exceptional attention to detail. –
- Ability to research regulations and guidelines and adapt to print materials. –
- Ability to effectively work independently or collaboratively with others. –
- Excellent written/verbal communication and interpersonal skills. –
- Exceptional organizational skills. –
- Demonstrates excellent judgment. –
- Ability to meet strict, time sensitive deadlines. –
- Must be proficient with Microsoft Office, including intermediate level of Excel and Word or higher. Fluency in Spanish preferred.
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