Appeals & Grievance Analyst - Health Alliance Plan
Company: Henry Ford Hospital
Location: Troy
Posted on: January 5, 2021
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Job Description:
GENERAL SUMMARY: Responsible for the prompt and thorough
investigation of medical, transportation, and pharmacy member
appeals and grievances for Health Alliance Plan's (HAP's):
Commercial, Medicare Advantage, Medicare-Medicaid Program (MMP),
and Medicaid lines of business. Analyst must identify trending
issues on an ongoing basis and provide root/cause analysis when
required. Analyst will work with HAP's medical directors, nurses,
pharmacists, Legal department, and other subject matter experts to
determine appropriate outcomes for all cases. In addition, in this
role the analyst will be required to keep abreast of regulatory
requirements from State and Federal agencies and speak before
members, senior leaders and other key stakeholders to present
appeal cases on an ongoing basis. The analyst will also provide
necessary support for audits and the development of desk level
procedures. PRINCIPLE DUTIES AND RESPONSIBILITIES: Conduct the
primary investigation and resolution of member appeals and
grievances following established guidelines from: The Center for
Medicaid and Medicare Services (CMS), MAXIMUS Federal Services,
Department of Labor (DOL), Department of Insurance and Financial
Services (DIFS), Michigan Department of Health and Human Services
(MDHHS), National Committee for Quality Assurance (NCQA), Office of
Personnel Management (OPM), MI Health Link, and Better Business
Bureau (BBB). Demonstrate strict adherence to the Centers for
Medicare and Medicaid (CMS), MI Health Link (MMP), and Michigan
Department of Health and Human Services (MDHHS) contracts in the
responses to members and regulatory agencies. Provide concise and
thorough written responses to members and regulatory agencies
regarding the findings of their investigations Perform case
pre-analysis, and procure appropriate medical records and
supporting documentation prior to sending case to internal
stakeholders for subject matter expert reviews Prepare cases for
presentation during pertinent hearings (e.g. Administrative Law
Judge hearings, MAXIMUS Committee Meetings, State Fair Hearings,
Second-Level Member Hearings) Perform other related duties as
assigned. EDUCATION/EXPERIENCE REQUIRED: Bachelor's Degree in
healthcare or a related field. At least three of the following
bulleted items is needed in combination with successful experience
with business writing which will be demonstrated by passing a
writing assessment: Minimum of two (2) years of experience working
in a managed care environment investigating appeals. Minimum of two
(2) years of experience working with Medicare, Commercial, and
Medicaid/MMP appeals and grievances. Minimum of two (2) years of
experience working in a managed care environment investigating and
resolving complaints or grievances. Minimum of two (2) years of
experience working on utilization management platform-processing
authorizations. Minimum of two (2) years of experience compiling
data for appeal review with regulatory entities. Minimum of two (2)
years of experience performing quality management case reviews.
Requires a successfully completed written assessment. Must
demonstrate strong analytical and critical thinking skills. Must
possess a very high degree of patience, maturity, empathy, tact and
diplomacy and be able to work with all levels of people within the
organization. A demonstrated ability to work in a Windows
environment, HAP's current documentation system (Pega A&G, Pega
CRM and Microsoft Word). Demonstrated knowledge of the Medicare
Advantage, Federal Government, Medicare benefits, all Commercial
including Self-Funded benefit guides, contracts and riders,
eligibility and direct pay programs and rates. Demonstrated
knowledge of billing/claims and customer service functions in a
healthcare environment. Knowledge of medical terminology.
CERTIFICATIONS/LICENSURES REQUIRED: Minimum of two (2) years of
experience as a Licensed Practical Nurse (LPN) in the State of
Michigan preferred. Minimum of two (2) years of experience as a
Registered Health Information Technician (RHIT) preferred.
Keywords: Henry Ford Hospital, Troy , Appeals & Grievance Analyst - Health Alliance Plan, Professions , Troy, Michigan
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