Medicare Grievance Lead

Job Description

Title: Medicare Grievance Lead

Location: Remote, United States

Responsibilities:

The Grievance Lead (GL) is responsible of providing support and direction for the daily operations of the Grievance Department function as follows:

Assist in ensuring the Grievance Department meets the regulatory compliance, timeliness requirements and accuracy standards when processing Part C and Part D Medicare Advantage grievances based on the requirement set forth by the Centers for Medicare and Medicaid (CMS).
Responsible for staying current on the latest information from CMS and AHC Compliance Department that effects member benefits, regulatory changes, and to ensure that the department adherence to established policies and procedures regarding the grievance process.

Ensure operations and processes of the department are followed according to the defined internal processes and procedures in coordination with the Supervisor MCR Grievances and CTMs.
Reviews work procedures and recommends or changes to procedures to improve efficiency by recognizes and resolving problems impacting department processes by collecting and analyzing information; communicates suggestions to management and develops/implements solutions as appropriate.
Ability to communicate and any changes to the grievance process and provide training on new processes as they are identified.

Conducts grievance case reviews: Assesses whether case was appropriately handled as a service issue or administrative request and was correctly processed to avoid service delays. Reviews case documentation and member facing letters to assess appropriate system entries have been made and the step-by-step actions are correct for the type of grievance. Ensures resolution is clear and addresses all grievance issues. Ensures applicability of, and compliance with, federal and state regulations, enterprise policies and procedures and all related standards in coordination with the MCR Grievance Supervisor.
Provides necessary coaching and guidance to the staff as needed and will work closely with the MCECE Manager, Supervisor MCR Grievances and CTMs, MCECE Quality Oversight team, and Business Analyst to identify further coaching/training opportunities, patterns, and trends from the grievances and opportunities to streamline and improve processes.
Assists management in process improvement strategies to achieve department objectives.

Assists the Supervisor MCR Grievances and CTMs with monthly or quarter audit findings and recommendations for Grievance Investigators on a monthly basis, or as needed.
Assists in the identification and communication of error trends to improve overall quality of Grievance team.
In conjunction with the Supervisor MCR Grievances and CTMs, monitors team performance and trends, and coaches’ staff to ensure adherence to policies, procedures, and the highest level of customer service via weekly case reviews with Grievance Investigation Specialists.

Manages case inventory and case loading to ensure regulatory and departmental standards are met.
Handles a reduced caseload of grievances based on volume. Handle CTMs and escalated member grievance cases/calls, as needed.
Responsible for prompt communication with staff.
As needed, co-facilitate weekly team huddle meetings or adhoc meeting that is needed for the department.

Must be able to accomplish duties and assignments with minimal supervision.
Responsible for special assignments or projects as requested by Grievance management.
Attend seminars, workshops, and conferences to improve existing job knowledge

Education/ Experience:

3 to 5 years of experience with Medicare grievance processing.
Bachelor’s Degree plus 2 years of work experience in a related field; credits equivalent to at least 2 years of college plus 4 years work experience in a managed care environment; or minimum 3-5 years of experience with Medicare grievance processing.
BSW or equivalent preferred.
Clear understanding of Medicare Part C and Part D appeals and grievance requirements based on the MMCM for Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance.

Understand and responsible for classification, processing, and resolution of grievances from members, as needed.
Research issues utilizing systems and time management assessment skills, knowledge, and department “Support Tools” in the investigation and resolution making process regarding services and care grievances for members.
Make critical decisions regarding research and investigation to appropriately resolve all grievances.

Based on analysis of issues, reaches out to appropriate internal or external entities and validating their responses.
Responsible for ensuring grievance cases are completed within the applicable regulatory timeframe.
Prepares and ensures that the Grievance Team is developing professionally written and customized responses to all member resolution letters that appropriately and completely address the complainant’s issue(s) and are structurally accurate.

Ensures customized and timely acknowledgment for all member grievance requests.
Ability to independently monitor their daily and weekly case load.
Closes case files independently without prospective quality reviews, while mentoring and assisting other specialists to achieve the same goal.

Ability to conduct all necessary follow-up calls to internal and external entities to ensure that cases are completed on or before the applicable timeframe.
Ensures that Grievance Investigators are entering all details of the actions taken in the investigation of the case.
Conduct root cause analysis and propose resolution of individual and global issues.

Provide recommendations to management regarding cost saving opportunities, best practices, and performance issues.