Virginia Premier Health Plan, Inc.

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Grievances and Appeals Coordinator (Medicaid)

Grievances and Appeals Coordinator (Medicaid)

Job Locations 
US-VA-Glen Allen
Job ID 
2017-4124

Job Description

Overview

The Grievances & Appeals Coordinator core function includes responsibility for informing and educating plan members and practitioners on the process to properly submit a formal grievance and/or appeal. The incumbent of this position manages, investigates and resolves member and practitioner grievances/appeals, to include appeals related to medication medical or service denials pursuant to Virginia Premier Health Plan’s (VPHP) and Virginia Premier CompleteCare (VPCC) policies and procedures, its regulatory and its accreditation requirements to include, but not limited to, meeting all required timeframes. The Grievances & Appeals Coordinator shall also be responsible for serving as the plan’s expert and liaison for the members and practitioners related to all grievance and appeals activities. Minimum travel may be required.

Responsibilities

  •  Responds to member and practitioner grievances/appeals with minimal direction; while assisting members, via phone or face to face, further/support quality related goals.
  • Investigates and resolves member and practitioner grievances/appeals within plan, regulatory and accreditation timeframes
  • Prepares, attends and presents grievances/appeals documentation for plan, regulatory hearings and/or during audits, as needed
  • Prepares all grievances/appeals written documentation
  • Documents all grievances/appeals in an accurate and timely manner per policy, related follow-up activities and final outcomes in designated systems while concurrently maintaining secure, comprehensive and clearly defined files
  • Provides timely assistance to members and practitioners in filing a formal grievance/ appeal and ensures that members and practitioners are advised of their appeal rights
  • Works collaboratively, coordinates, communicates and integrates recommendations from impacted organizational departments and/or Senior Level Executives and other designated staff, as approved and required
  • Generates reports with trend analysis and recommendations for quality improvement to Manager, as required
  • Communicates detailed account of risk management issues to the Manager within the specified timeframe
  • Assists with training, in-services and quality audits as a result of plan, regulatory or accreditation requirements
  • Assists with any/other project management duties, as needed
  • Assists with accreditation related duties, as needed
  • Attend MAC and PAC meetings, as needed
  • Maintains strict confidentiality
  • Maintains current knowledge of VPHP and VPCC policies and procedures

 

 

Qualifications

MINIMUM EDUCATION REQUIREMENTS

  • Bachelor degree in a health care related field (preferred)

SPECIAL KNOWLEDGE AND/OR SKILLS

  • Strong written and oral communication skills
  • Bilingual communication skills preferred (Spanish speaking preferred)
  • Exceptional interpersonal and problem solving skills
  • Positive and approachable demeanor
  • Flexible (Outside of the Box) Thinker
  • Must be able to multi-task
  • Working knowledge of the Grievances/Appeals Processes and related legislation
  • Knowledge of medical terminology
  • Knowledge of the managed care industry
  • Demonstrated experience in quality project management from start to finish to include, but not limited to receiving a request, data/document finding, ensuring proper and timely assessment of data by the appropriate staff, resolution and follow-up, as required
  • Computer experience with Microsoft office software including Access and Excel

WORK BACKGROUND/EXPERIENCE

  • Customer service experience in a medical environment
  • Knowledge of Medicare and Medicaid
  • Experience applying accreditation and regulatory requirements and ensuring ongoing compliance
  • Ability to succinctly deliver pertinent information to a variety of audiences to include members, practitioners, organizational executives, attorneys and/or accreditation and regulatory auditors
  • Working knowledge of computers and word processing programs
  • Experience working with low income, indigent and/or disadvantaged populations

PHYSICAL REQUIREMENTS

Physical health sufficient to meet the ergonomic standards and demands of the position.

  

About Us

Virginia Premier Health Plan, Inc. is a managed care organization which began as a full-service Medicaid MCO in 1995. Partnered with VCU Medical Systems we strive to meet the needs of the underserved and vulnerable populations in Virginia by delivering quality driven, culturally sensitive and financially viable Medicare and Medicaid healthcare programs.  Headquartered in Richmond, VA we also have offices in Roanoke, Tidewater and Bristol with additional satellite locations allowing us to serve over 200,000 members across eighty counties throughout Virginia. 

 

We offer competitive salaries and a comprehensive benefits package to include excellent Medical, Dental and Vision Plans, Tuition Assistance, Infant-At-Work Program, Remote Work options and generous vacation and sick leave policies. Our culture supports an environment where employees can continuously learn and gain professional growth through various development programs, education, exciting projects and career mobility.  

 

All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. EOE

 

Our mission is to inspire healthy living within the communities we serve!

 

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