Appeals & Grievances Nurse

 

PURPOSE OF THE POSITION:  

Under the direction of the Senior Manager-Complaint, Grievance and Appeal Unit, the Complaint, Grievance and Appeal Coordinator is responsible for maintaining the corporate-wide Member complaint, grievance and appeal process, including triage, investigation, timely and accurate case resolution, reporting, trending, follow-up and performance improvement initiatives associated with all Member complaints/grievances/appeals. May concentrate in either complaints, grievances or appeals.

ESSENTIAL FUNCTIONS:

1.  Receives all complaints made by Members, determines whether Medicare Members are filing a grievance or an appeal, and ensures entry into the corporate complaint/grievance software application.

2. Triages all complaints/grievances/appeals; documents correct category and assessment, and assigns to appropriate Affinity departments or retains for investigation.

3. Conducts full investigations of all quality of care complaints/grievances and all appeals, inclusive of review of medical records, interviews and site visits as indicated, including follow-up of requested provider performance improvement actions.

4. Generates and documents all written correspondence to Members, Providers, and Affinity departments according to mandatory timeframes.

5. Ensures that all regulations governing appeals processing are implemented timely and accurately, and that the Medical Director is provided complete information for decision-making purposes.

6.  Maintains a tracking system for all complaints/grievances and appeals of same, and ensures that they are investigated and resolved timely and correctly per regulatory guidelines.

7.  Reviews all Member resolution letters and ensures timely and appropriate communication with the complainant.

8.  Communicates and updates the Senior Manager-Complaint, Grievance and Appeal Unit and the Medical Director on all complaints and appeals in an ongoing fashion.

9.  Maintains confidential files of all complaints/grievances/appeals and related activities and serves as a liaison between Members, providers, Affinity Staff and external agencies in the complaint/grievance/appeals resolution process.

10.  Ensures that complaint/grievance summaries involving Affinity providers are placed in individual credentialing files as appropriate.

11.  Participates in the development and implementation of process and/or performance improvement activities related to the findings of individual and trended complaints/grievances/appeals.

12.  Assists in the training of Unit and Department staff assigned to support the Member complaint/grievance/appeal program.

13.  Contributes to the development of training manuals for staff and complaint/grievance/appeals investigators; helps maintain and keep current all policies and procedures, and attends meetings as indicated.

14.  Produces required and/or requested reports for internal committees and external agencies; presents to audiences as requested.

15.  Serves on the Affinity Corporate Member Complaints and Satisfaction Committee. Supports the work of the committee through preparing agendas, providing documentation, presenting data and maintaining minutes as generated.

16.  Demonstrate proficiency with the principles and methodologies of process improvement.  Apply these in the execution of responsibilities in support of a process focused approach.

17.  Performs other duties as necessary or assigned.

QUALIFICATIONS:

  • New York State Registered Nurse or equivalent clinical training
  • Bachelor’s Degree in related field or equivalent knowledge
  • Minimum two years nursing experience; managed care experience a plus
  • Knowledge of HMO/DOH regulatory guidelines, member complaint experience and/or risk management background a plus
  • Working knowledge of Microsoft Word/Excel; database expertise a plus
  • Ability to prioritize and multitask effectively
  • Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action
  • Excellent verbal and written communication skills; ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others.
  • Ability to work resourcefully and creatively, to think independently, and to exercise sound judgment in a complex and dynamic environment.
  • Commitment to the corporate mission, vision, and values.
  • High level of integrity as demonstrated by a) appropriate treatment of confidential information, b) adherence to policies, procedures, rules and regulations, c) professional conduct in dealing with persons internal and external to the organization, and d) sensitivity to the populations served by Affinity and the providers with which Affinity works.