RN Health Plan Grievance & Appeals Specialist - Denver Health Medical Plan (Must Be a Colorado Resident)
- Denver, CO
- $72,400-112,200 per year
- Permanent
- Full-time
Where is your life journey taking you?Being the heartbeat of Denver means our heart reflects something bigger than ourselves, something that connects us all:Humanity in action, Triumph in hardship, Transformation in health.Department Managed Care AdministrationMust Be a Colorado ResidentJob SummaryUnder minimal supervision, the Registered Nurse, Grievance & Appeals is responsible for assessing and completing appropriate documentation for tracking and trending, including conducting all pertinent research, in order to evaluate, respond, and close grievances and appeals for Denver Health Medical Plan's members, member representatives, contracted rental networks, hospitals, physician groups, primary care physicians, specialty care physicians and other individual health care providers in accordance with the Plan's adjudication and determination policies. Ensures that all Member Grievances and Appeals and Provider Resubmissions, Reconsiderations and Appeals, including all incoming correspondence, are properly processed on a timely basis.Essential Functions:
- Maintains grievance and appeal information as well as supporting documentation in accordance with regulatory bodies for all lines of business at the Medical Plan. (10%)
- Notifies appropriate channels in compliance of all regulations and policies, while balancing the need to produce high quality work related to complex and sensitive issues. (10%)
- Proposes recommendations and decisions to all grievances and appeals through internal and external communications. (10%)
- Coordinates the compilation of appeal case files for transmission to third-party reviewers, physician reviewers, and independent reviewer entities. (5%)
- Maintains knowledge of current regulatory standards, internal policies, and procedures and ensures compliance at all times. (10%)
- Maintains knowledge and information on contract terms and benefit plans for all Plan lines of business. (5%)
- Consults and communicates effectively with Appeals Manager, senior leaders and other departments in the investigation and disposition of the grievance or appeals as deemed necessary or in compliance of regulatory requirements. (20%)
- Leverages both written and verbal communications; and ensures all provider resolution communications are timely, as well as organized, accurate, comprehensive, and crafted professionally. (10%)
- Conduct and Review Quality of Care Concern Complaints (10%)
- Perform Utilization Reviews for 1st Level Appeals by utilizing MCG (evidence-based medical criteria) (10%)
- Associate's Degree Registered Nurse required
- 1-3 years experience in a managed care health insurance plan required. Previous grievance and appeals experience preferred.
- RN-Registered Nurse - DORA - Department of Regulatory Agencies required
- Ability to investigate and analyze appeals with a level of thoroughness and in a timely manner.
- Ability to listen effectively and appropriately respond to difficult and urgent situations.
- Demonstrates strong analytical and research skills and the ability to solve problems creatively, objectively, and rapidly.
- Excellent interpersonal and verbal communication skills, including conflict resolution and mediation.
- Ability to write summaries, prepare reports, and write comprehensive letters using proper grammar and sentence structure.
- Must have a thorough understanding and working knowledge of managed care, health insurance plans, regulatory, and other policies and procedures, including grievance and appeals practices.
- Has critical thinking skills, ability to prioritize issues, handles sensitive issues with confidentiality, tact, and diplomacy.
- Ability to cope with a very high volume of tasks on a tight timeline under demanding conditions.
- Ability to adapt to a constantly changing environment and ability to work independently and with a team.
- Proficiency with the Microsoft Office Suite
- Experience with Data Entry Software
- Familiarity with various office equipment