Complaints/Appeals & Grievances Specialist
Full Time, Non-Exempt, Monday – Friday
The Complaints/Appeals & Grievances Specialist has primary responsibility for handling member Appeals and Grievances (A&G) according to State and Federal regulations and time frames, and in accordance with PrimeWest Health policy. The Complaints/Appeals & Grievances Specialist takes direction from the Manager of Quality Management regarding the administration of member State Appeals (Fair Hearings with the State), and A&G. This position also assists with Part C and Part D processes related to Data Validation audits. This individual will maintain strict confidentiality of all sensitive information and will maintain documentation of State Appeals (Fair Hearings with the State) and A&G in accordance with Minnesota Department of Human Services (DHS) and Centers for Medicare & Medicaid Services (CMS) standards. The Complaints/Appeals & Grievances Specialist is responsible for maintaining interdepartmental documentation of communication and relationships with key PrimeWest Health partners as directed by the Manager of Quality Management and Director of Quality & Utilization Management. All duties related to State Appeals (Fair Hearings with the State) and A&G are performed in collaboration with the PrimeWest Health Chief Senior Medical Director and under the direction of the Manager of Quality Management and/or Director of Quality & Utilization Management.
Reporting Accountability This position is responsible for meeting the following regulatory, contractual, or other requirements on behalf of PrimeWest Health:
- Ensure compliance with all regulatory and contractual requirements related to the Quality & Utilization Management department
Role and Key Responsibilities
Assist the Manager of Quality Management and other PrimeWest Health staff in the following as needed:
- Answer incoming calls not disbursed by voicemail system in an efficient and prompt manner and handle or route calls to other staff as needed. Maintain a pleasant and cheerful phone manner. Monitor and clear voicemail message, if needed, on a regular and timely basis. Ensure phone backup when away from desk. Maintain documentation in an accessible location on how calls are routed to office staff.
- Provide support to the Manager of Quality Management and Director of Quality & Utilization Management as needed. This includes assisting with report and application submissions, making copies, faxing documents, constructing letters/documents, and preparing mailings.
- File electronic and hard copy documents with regulators
- Assist with data entry and retrieval and graph and chart development as needed
- Record meeting minutes as requested
- Coordinate and arrange meetings and catering as requested
- Attend State Appeal (Fair Hearing with the State) meetings as requested
- Assist with the submission of quarterly electronic reports for oral/written Appeals and oral/written Grievances to the State
- Prepare Data Validation reports for measures related to A&G in accordance with CMS requirements
- Handle State Appeals (Fair Hearings with the State) and A&Gs as necessary to ensure that all concerns are responded to and resolved appropriately
- Check systems on weekends and holidays for expedited A&G requests via an on-call rotation
- Work closely with the Quality Specialist regarding Quality of Care issues
- Stay current on all new legislation and statutes as well as amendments to assist with appropriate and compliant documentation and handling and reporting of A&G processes
- Organize State Appeals (Fair Hearings with the State) and A&G complaints, including creation of a summary of quarterly activities for PrimeWest Health’s Quality and Care Coordination Committee (QCCC)
- Increase member satisfaction by providing professional and accurate responses to complaints regarding benefits, eligibility, authorization, claims, and pharmacy issues; ensure that all concerns are responded to and resolved appropriately and expeditiously
- Assist the Quality Specialist with administrative tasks related to QCCC meetings
- Participate in the Weekly Grievance Review Workgroup
- Provide additional support to Quality staff as needed, including, but not limited to, coordinating medical record requests, performing data entry tasks, and assisting with quality assurance activities
General PrimeWest Health Responsibilities
- Abide by the PrimeWest Health Code of Conduct Comply with all PrimeWest Health policies and procedures Comply with the Health Insurance Portability and Accountability Act (HIPAA) and all other privacy laws Be familiar with building safety procedures and alert maintenance if something requires attention Keep public areas of the department and office neat and clean Conduct other responsibilities and activities as needed and assigned
- Strong interpersonal and communication skills
Educational Requirements and Required Qualifications
- At minimum, an associate degree or diploma in administrative assistance or two years of experience equivalent to the position requirements Demonstrated knowledge of, and proficiency in, Word, Excel, and Outlook required. Experience in word processing and relational databases is a plus. Flexibility and ability to handle multiple tasks. Demonstrated organizational skills and attention to detail. Ability to work effectively with a variety of people both within and outside of the organization. Good verbal and written communication skills. Ability to sit at a desk or computer station most of the time. Ability to occasionally lift and/or carry such articles as file folders and small boxes up to 30 pounds.
Appropriate Licensure and Certification Requirements – N/A
Collaborative Efforts with Other Departments
- Administration Business IT & Claims Administration Care & Population Health Management Corporate Compliance & Auditing Information Systems & Technology Member & Provider Services Operations Pharmacy Management
Supervision – N/A
This position description is not to be construed as an exhaustive statement of essential functions or responsibilities.
Alexandria, Minnesota – This position offers the possibility for remote/hybrid work
PrimeWest Health is an Equal Opportunity Employer Committed to Diversity, Equity, and Inclusion