Member Appeal & Grievance Coordinator-ACO-CC

About us:

Fallon Health is a company that cares. We prioritize our members-always-making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation's top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs-including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)- in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.

Brief summary of purpose:

The Fallon Health (FH) Appeals and Grievance process is an essential function to FH compliance with CMS regulations, NCQA standards, other applicable regulatory requirements and member expectations. The FH Member Appeals & Grievances Coordinator serves to administer the FH Appeals and Grievance process as outlined in the Member Handbook/Evidence of Coverage, departmental policies and procedures, and regulatory standards. The Member Appeals & Grievances Coordinator serves as a liaison between FH members and FH with their complaints regarding denied claims, referrals, membership, and benefit issues as well as any grievances regarding quality of care or service. The Member Appeals & Grievances Coordinator is responsible for the presentation of the member appeal to the FH Medical Director, Center for Medicare/Medicaid Services, contracted reviewer, as well as the contracted external review agency in accordance with applicable laws, organization policies, and regulatory requirements. Thorough research, documentation, and corrective action planning must be established for each respective case and completed in accordance with existing regulations, policies and standards.

Administrate FH Standard and Expedited Appeals Processes as outlined in Member Handbook/Evidence of Coverage for all products, and in compliance with applicable NCQA standards and other state or federal regulatory requirements. Strict adherence to department turn-around time standards established in accordance with regulatory standards is required.

Act as the primary investigator and contact person for member grievances and appeals, which includes, educating the member and/or member representative about the grievance/appeal, gathering all pertinent and relevant information from the member regarding the grievance/appeal, notifying the appropriate parties of the resolution and ensuring that all internal processes are completed to resolve the issue.

Print and mail member letters at FH corporate office located at 10 Chestnut Street, Worcester, MA several times per month and/or a needed, as designated through a rotational in-office calendar or at the direction of a supervisor or manager.

Answers telephone calls via ACD queue, as needed, within the FH's standards for quality and service.

Ability to interpret and operationalize multiple products, the regulatory requirements and differences within each.

Ability to multitask and respond quickly and accurately to issues and concerns for members and internal departments.

Research, investigate, and document all action taken on behalf of the member to resolve the grievance/appeal.

On-call approximately one holiday (3-day) weekend per year and two (2-day) weekend every 5 weeks and as needed.

Available by cell phone to accept new expedited appeal requests and, where necessary, to present to the FH office to process requests within applicable turn-around time standard.

Special projects as assigned by Management.

Conduct case management of legal/risk issues regarding member complaints, weighing interests of all customers, both internal and external.

Adhering to FH confidentiality policy; document, research and review member complaints, involving quality of care or quality of service with appropriate clinical and/or administrative staff.

Work with Team Leaders, Department Managers, Department Chairs and/or Medical Director to resolve member complaints; formulate improvement measures and responses to member; prepare written correspondence to members.

Forward all documentation involving member quality of care or quality of service complaints to FH administration and FH Quality Management Department.

Adhere to department standards for completion of member complaints.

Research and resolve system-wide issues, deficiencies, problems and formulate quality improvement measures. Ensure that all grievances/appeals are processed in adherence to state and federal regulations (i.e., CMS, MassHealth, OPP), contractual obligations, NCQA guidelines and FH policy.

Education:

Bachelor of Science or Arts preferred but not required. Equivalent work experience is acceptable.

License/Certifications:

Reasonable transportation is required.

Experience:

1-3 years previous professional experience in related position (preferably in healthcare)

Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.