Grievance and Appeals Specialist (44017)

The Grievance and Appeals Specialist is responsible for handling member and provider grievances, complaints, appeals and provider claim disputes across all product lines. This role ensures compliance with contractual and regulatory requirements, including those issued by the Centers for Medicare and Medicaid Services (CMS), Executive Office of the Health and Human Services (EOHHS), Office of the Health Insurance Commissioner (OHIC), National Committee for Quality Assurance (NCQA) and other applicable standards, while meeting all turnaround times.

The Specialist interprets and explains benefits, policies, and procedures to members and providers, tracks case progress, and ensures timely resolution. In addition, the Specialist will maintain accurate documentation for reporting and audits, identify trends and collaborate across departments to improve processes and member experience.

Duties and Responsibilities:

Responsibilities include but are not limited to:

• Responsible for accurate identification of all Medicaid, Medicare and Commercial grievances, appeals, and complaints, including potential Quality of Care complaints or grievances and provider claims disputes
• Review and evaluate all grievances, appeals and complaints submitted to the organization while adhering to established timelines and initiate electronic tracking and distribution to the appropriate department for resolution
• Responsible for all aspects of provider claim disputes including issue creation, reviewing, resolving and development of written communication to providers
• Interpret and explain the organization’s benefits, policies and procedures to members and providers related to grievances, appeals and complaints
• Communicate with members/providers as necessary to provide updates or obtain additional information needed for decision making on complaints, grievance and appeals
• Generate timely and compliant initial member acknowledgment (verbal and/or written)
• Initiate electronic tracking of all grievances, appeals, provider claims disputes and complaints including scanning of documents as needed and attaching to the member record
• Monitor progress of each grievance, appeal, provider claims disputes and complaint by using reports and tracking techniques to ensure decisions are rendered within the required time frames
• Follow-up with responsible departments and delegated entities to ensure compliance
• Document final resolution along with all required data to facilitate accurate reporting
• Ensure final resolution letters are compliant and generated within the required timelines
• Quality checks member and provider facing letters and when appropriate obtains legal opinion on language
• Build effective and successful inter-departmental relationships with all areas of the company and utilize good communication and customer service skills in responding to internal and external inquiries about the grievance, appeal and complaint processes while being able to respond quickly regarding the status.
• Collaborate with the designated GAU Reporting Analyst and GAU Manager to generate required reports on a pre-determined or ad-hoc basis, including but not limited to CMS, EOHHS and OHIC requirements
• Participate in compiling grievance, appeal, and complaint records selected for on-site audits
• Other duties as assigned
• Corporate Compliance Responsibility – As an essential function, responsible for complying with Neighborhood’s Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents

Qualifications

Required:

• Associate’s degree in business-related discipline or equivalent education and relevant work experience in lieu of a degree.
• Four (4) + years’ work experience in managed care, healthcare or health insurance
• Strong analytical and problem-solving skills with ability to identify issues and draw valid conclusions.
• Basic to intermediate knowledge of medical terminology and CPT and ICD10 coding.
• Knowledge of state and federal laws governing grievances, appeals and complaints.
• Familiarity with CMS regulations and Medicare rules.
• Excellent organizational, prioritization, and time management skills.
• Strong customer service orientation and professional communication skills.
• Proficiency in Microsoft Office (Word, Excel, PowerPoint, Outlook).
• Experience with healthcare management systems and claim adjudication platforms.
• Ability to work flexible hours, including evening/weekends if needed.

Preferred:

• Bachelor’s degree in healthcare administration or business-related field
• Previous work experience with Medicare, Medicaid and Commercial benefits and compliance
• Previous experience in grievance and appeals coordination or senior-level roles
• Experience in communicating with provider networks
• Certified Professional Coder (CPC)
• Experience with claim payment and adjudication systems
• Effective interpersonal communication skills, both verbal and written

Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.