Grievance &Appeals Specialist, Clinical RN

VNS Health; New York (NY); On-site; USD 93,000 - 117,000; Full time

Job summary

VNS Health in New York seeks a registered nurse to resolve grievances, appeals and external reviews for MLTC/MA/select Health products. You will ensure regulatory compliance and timeliness, maintain records, and communicate outcomes to enrollees and providers.

The role requires NY RN license, Bachelor's or Master's in Nursing preferred, and at least three years in healthcare including two in grievance or related areas.

Qualifications

• Licensed and current NYS RN license
• Bachelor's or Master's in Nursing preferred
• Three years of progressive health-care experience, including two years in grievance/appeals or related area
• Proficient verbal/written communication and strong computer skills
• Ability to work in a fast-paced environment and manage multiple grievances and appeals

Responsibilities

• Resolves grievances, appeals and external reviews for specified VNS Health Plans
• Ensures regulatory compliance and timeliness in processing
• Maintains accurate records documenting actions and rationale
• Develops correspondence communicating outcomes to enrollees/providers
• Assists with data collection and reporting
• Coordinates with Claims, Medical Management and third-party staff as needed

Skills

Verbal & written communication

MS Office proficiency

Typing speed

Case management

Education

Bachelor's Degree in Nursing

Master's Degree in Nursing

Tools

Microsoft Office

Job description

Overview

Resolves grievances, appeals and external reviews for one of the following VNS Health Plans product lines – Managed Long Term Care (MLTC), Medicare Advantage (MA), or 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. Works under general supervision.

• 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, focusing primarily on issues of medical necessity, quality of care, long term services and supports, etc.. 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.
• Participates in special projects and performs other duties as assigned.

Qualifications

Licenses and Certifications: License and current registration to practice as a registered professional nurse in New York State required

Education: Bachelor's Degree or Master's Degree in Nursing 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 requiredProficient verbal/written communication skills requiredProficient computer and typing skills and knowledge of Microsoft Office (Word and Excel) requiredAbility to work in a fast paced environment and effectively manage multiple grievances and appeals simultaneously.

Pay Range

USD $93,400.00 - USD $116,800.00 /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.