Responsibilities:

• Represent the service coordination team as an employee voter on first level appeals and as a witness for State Fair Hearings.
• Act as subject matter expert on LTSS for first level appeals and State Fair Hearings.
• Research Participant cases to have full understanding of the PCSP, appeals and grievance requests, includes review of UM/claim denial reasons, contract/regulatory rules, benefits and documentation received on appeal/grievance.
• Present testimony on behalf of the Plan in State Fair Hearings.
• Facilitate information gathering from participants/representative during first level appeals.
• Contribute to first level appeal deliberations and decisions as part of interdisciplinary team.
• Maintains familiarity and compliance with federal, state and local regulations as well as other regulatory requirements (e.g. NCQA standards) relative to appeal and grievance operations and State Fair Hearings.
• Maintains quality and compliance standards as dictated by the state and federal entities.
• Maintains contractual agreements with participating providers related to appeals and grievances.
• Collaboration with internal counterparts as needed to ensure proper handling of the appeal e.g. LTSS UM team, medical directors, service coordination.
• Maintains accurate, timely, and complete record and documentation of appeals and state fair hearings, outcomes, follow up and resolution.
• Administrative tasks, including, but not limited to, letter processing, data collection and assembling/filing completed appeals folders.
• Reviews and properly distributes incoming appeals/grievance information on a department-wide basis.
• Ensures timely communication between the LTSS Review UM Department, the Appeals Committee, and the Service Coordination Department through the entire grievance and appeals processes.
• Follows-up with the Service Coordination Department after a decision is rendered to ensure the appropriate care plan is in place.
• Ensures timely notification of appeals and grievances and responds accordingly.
• Ensures compliance with organizational and CHC guidelines.
• Identifies process bottlenecks and areas of needed education or improvement and makes suggestions for remediation.
• Other tasks as assigned.

Education/ Experience:

• Bachelor’s Degree.
• LTSS Experience Required.
• General office experience required.
• Microsoft Office Suit experience required.
• Managed care experience preferred.
• 3 to 5 years experience.