Grievances & Appeals Coordinator

Position Summary:


As a part of the Quality Department, this position investigates and finds resolution of complaints, grievances and member appeals based upon specific regulatory requirements. In addition, the assembly and preparation of State Fair Hearing/IRO packets as well as coordination and participation in State Fair Hearings.


Essential Duties and Responsibilities:

1. Receives, researches, resolves, tracks trends, and reports all complaints, grievances, and appeals for all lines of business.
2. Maintains complaint, grievance, and appeal logs for all lines of business.
3. Responsible for case development and resolution of all complaints, grievances and appeals. The end-to-end process requires the coordinator to:
   • Research issues and obtain additional documentation as applicable
   • Reference and understand CCP's internal policies and procedures to frame decisions.
   • Interpret regulations
   • Resolve cases and make critical decisions
   • Manage all duties within regulatory timeframes
   • Finalize and send acknowledgment and resolution correspondence

1. Oversees the resolution of member complaints, grievances, and appeals related to quality of care and service, medical necessity, plan benefits and payments to ensure compliance with state and federal regulations and NCQA standards.
2. Coordinates monthly and ad hoc grievance and appeals committee meetings.
3. Communicate grievance and appeals decision to the participant within regulatory guidelines for timeliness, adhering to the strictest of timeframes for urgent and non-urgent requests, as imposed by the various federal and state laws.
4. Ensures thorough, accurate and timely processing of appeals using the internal appeals, independent external review or Medicaid Fair Hearing process.
5. Analyze complaint, grievance and appeal data, develop trend reports and work with various committees to identify opportunities for improvement to increase member satisfaction.
6. Monitor delegated partners in care complaint, grievance and appeal activity to ensure compliance.
7. Partner with other business areas to identify issues and develop appropriate action plans to address deficiencies.
8. Prepare comprehensive report for submission to the Agency for Healthcare Administration monthly and the Florida Healthy Kids Corporation quarterly.
9. Report data and make recommendations to the appropriate internal committees and workgroups such as the Quality Improvement Committee.
10. Maintain thorough knowledge of contract requirements, accreditation standards, and new and existing laws and regulations.
11. Develop, update and maintain grievance and appeal policies and procedures to support new lines of business and reflect changes in contract language, accreditation standards and updates in laws or regulations.
12. Design and implement departmental trainings to ensure quicker resolution of member issues and a better understanding of member appeal rights.
13. Work with internal stakeholders in federal, state, and/or internal audits of grievance and appeals processes as well as data validation activities, as needed. Takes the lead in presenting appeals and all grievance documentation during a mock or actual audit.
14. Perform other duties as necessary.

This job description in no way states or implies that these are the only duties performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by their supervisor or management.

Qualifications:

• Must have high school diploma or General Education degree (GED); Associates degree preferred; and two to four years related experience and/or training; or equivalent combination of education and experience.
• 1 to 2 years of health care experience.
• Conversant with HIPPA regulations, Medicaid and CHIP.
• Working knowledge of Microsoft software products such as Word and Excel.

Skills and Abilities:

• Problem solving- Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem solving situations; Uses reason even when dealing with emotional topics.
• Verbal communication-speaks clearly and persuasively in positive or negative situations; Listens and gets clarification; Responds well to questions; Demonstrates group presentation skills; Participates in meetings.
• Written communications-writes clearly and informatively; Edits work for spelling and grammar; Varies writing style to meet needs; Presents numerical data effectively; Able to read and interpret written information.
• Demonstrates flexibility with a willingness to learn and adapt to changes in regulations and task-related priorities

Work Schedule:

Community Care Plan is currently following a hybrid work schedule. The company reserves the right to change the work schedules based on the company needs.

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear. The employee is frequently required to stand, walk, and sit. The employee is occasionally required to stoop, kneel, crouch or crawl. The employee may occasionally lift and/or move up to 15 pounds.

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside/outside the office, travel to other offices, as well as domestic, travel. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.

We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating and preserving a culture of diversity, equity and inclusion.

Background Screening Notice:
In compliance with Florida law, candidates selected for this position must complete a Level 2 background screening through the Florida Care Provider Background Screening Clearinghouse.

The Clearinghouse is a statewide system managed by the Agency for Health Care Administration (AHCA) and is designed to help protect children, seniors, and other vulnerable populations while streamlining the screening process for employers and applicants.

Additional information is available at:
h