Grievance & Appeals Specialist

VNS Health; New York (NY); On-site; USD 66,000 - 80,000; Full time

Benefits offered by this job

Referral bonus opportunities

Generous PTO (30 days) and 9 holidays

Health insurance for you and family

Employer-matched retirement savings

Job summary

VNS Health in New York is seeking a Grievance and Appeals Specialist to resolve grievances, appeals and external reviews across MLTC, MA, FIDA and Select Health products, ensuring regulatory compliance and timely processing.

You will document actions, communicate outcomes, assist with data reporting, and collaborate with care teams and regulatory bodies. Grievance and appeals experience is required.

Qualifications

• Bachelor's degree in health/human services, healthcare or business administration or related field or equivalent work experience required.
• Master's Degree in public health or health-related field preferred.
• Proficient verbal/written communication skills and MS Office skills (Word/Excel) required.

Responsibilities

• Develops and maintains current knowledge of state and federal regulatory requirements related to grievances and appeals for Medicare managed care, Medicaid, home health care, MLTC and related requirements.
• Investigates and reviews routine and complex situations and underlying issues, analyzes and solves problems, and consults with enrollees, family, providers and plan departments as necessary.
• Coordinates resolution of routine and complex grievances and appeals according to defined processes, ensuring timeframes and regulatory requirements are met and documentation is completed.
• Reviews covered services against plan benefits and medical criteria to ensure appropriate appeal resolution and fiduciary compliance; prepares records for physician review as needed.
• Conducts review of requests for prior authorization of health services as required and prepares written responses.
• Coordinates external case reviews requested by enrollees, including documentation and tracking; external reviewers include NYS Fair Hearings, CMS, IROs and QIOs.
• Collaborates with Claims, Medical Management and third-party administrator staff to investigate and resolve grievances and appeals; consults with enrollees, providers and Medical Director as appropriate.
• Provides input for design and development of policies and procedures to improve department operations and customer service.
• Reviews information from Medicaid, Medicare and other payers regarding benefit levels and medical necessity criteria.

Skills

Grievance and appeals experience

Education

Bachelor's degree in health/ human services

Master's degree preferred

Tools

Microsoft Office (Word, Excel)

Job description

Overview

Resolves grievances, appeals and external reviews for VNS Health Plans product lines - Managed Long Term Care (MLTC), Medicare Advantage (MA), Fully Integrated Dual Advantage (FIDA) and Select Health. Ensures regulatory compliance, timeliness requirements and accuracy standards are met. Coordinates efficient functioning of day-to-day operations according to defined processes and procedures. Creates and maintains accurate records documenting the actions and rationale for each grievance or appeal decision. Develops correspondence communicating the outcome of grievances and appeals to enrollees and/or providers. Assists with collecting and reporting data. May assist in the case preparation and in-person representation at State Fair Hearing for MLTC and SelectHealth businesses. Works under general supervision.

Grievance and appeals experience required.

What We Provide:

• Referral bonus opportunities
• Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays
• Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life Disability
• Employer-matched retirement saving funds
• Personal and financial wellness programs
• Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care
• Generous tuition reimbursement for qualifying degrees
• Opportunities for professional growth and career advancement
• Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities

What You Will Do:

• Develops and maintains current knowledge of state and federal regulatory requirements related to all aspects of grievances and appeals for Medicare managed care organizations, Medicaid, home health care, managed long term care as well as contractual requirements.
• Investigates and reviews routine and complex situations and underlying issues, analyzes and solves problems. Consults with the member, family, providers and health plan departments as necessary. Identifies and communicates key points from details.
• Investigates and coordinates the resolution of routine and complex grievances and appeals according to defined processes and procedures ensuring that required timeframes and regulatory requirements are met, accurate and timely follow up is completed and activities are documented as required.
• Reviews covered and coordinated services in accordance with established plan benefits, application of medical criteria and regulatory requirements to ensure appropriate appeal resolution and execution of the plan's fiduciary responsibilities. Prepares records for physician review as needed.
• Conducts review of requests for prior authorization of health services, as required in certain product lines, and prepares written responses consistent with regulatory requirements.
• Coordinates external case reviews requested by enrollees, including preparing and submitting documentation according to regulatory requirements and tracking external reviews throughout the process. External reviewers include New York State (Fair Hearings), Centers for Medicare and Medicaid Services (CMS), Independent Review Entities and Quality Improvement Organizations.
• Collaborates with professionals, health plan departments such as Claims and Medical Management, and the third party administrator staff and legal, as necessary, to investigate and facilitate resolution of individual grievances and appeals. Consults with enrollees, providers and the Medical Director, as appropriate.
• Provides input and recommendations for design and development of policies, processes and procedures for improved department operations and customer service.
• Reviews information available from Medicaid, Medicare, other payers, and/or professional medical organizations regarding benefit levels and medical necessity criteria.
• Enters data and assists with compiling reports and analysis on the grievance and appeals process.

Qualifications

Education:

Bachelor's Degree in health/human services, healthcare or business administration or related field or equivalent work experience required. Master's Degree in public health or health-related field preferred

Work Experience:

Minimum three years progressive professional experience in health care, including a minimum of two years in a grievance and appeals or related area such as medical or utilization management in a Managed Care setting required. Proficient verbal/written communication skills required. Proficient computer and typing skills and knowledge of Microsoft Office (Word and Excel) required. Ability to work in a fast paced environment and effectively manage multiple grievances and appeals simultaneously.

Pay Range

USD $66,300.00 - USD $79,800.00 /Yr.

About Us

VNS Health has been committed to meeting the needs of New Yorkers for over 130 years. We're one of the largest nonprofit home- and community-based health care organizations in the country, and today, more than 11,500 team members work together to make a difference in the lives of more than 99,000 patients and members on any given day.