OPEN ONLY TO THOSE WHO RESIDE IN ARIZONACORE FUNCTIONS:Maintains State Fair Hearing Logs with appropriate information required by HP policy, AHCCCS, HCG, and CMS regulations. Reviews all State Fair Hearing requests by members and providers, pulls case files, meets with Grievance & Appeals Manager for further review and action, which may include collaboration with others to avoid/reduce grievances, appeals, and/or claim disputes. May attend State Fair Hearings. Coordinates and assists the Grievance & Appeals Manager in preparing for higher levels of appeals (i.e., Independent Review Entity reviews, hearings, etc.), including telephonic requests. Assists with project management of departmental improvements. Coordinates with other departments on Grievance & Appeals projects/workgroups. Assists the Marketing Department with the production of all member letters and notices. Participates actively in meetings, workgroups, and committees relevant to the Grievance & Appeals process. May produce, prepare, quality check, or deliver all reporting requirements in the absence of the Grievance & Appeals Manager. Produces and analyzes weekly and monthly data to determine trends and provides recommendations for intervention. Assists with internal, external, and self-audits of the department and annual data validation. Produces a Monthly Operational Dashboard. Produces, analyzes, and reports monthly data to ensure regulatory compliance. Updates Grievance & Appeals data in conjunction with the Marketing department on all HP websites. Monitors and resolves member and provider expedited appeals and grievances received after hours and/or holidays when assigned to rotational on-call duty. Coordinate appropriate action by supporting clinical staff for processing of member and provider expedited appeals and/or grievances. This position works under supervision, prioritizing data from multiple sources to provide quality care and support. Incumbents work in a fast-paced, sometimes stressful environment with a strong focus on customer service. Interacts with staff at all levels throughout the organization.
MINIMUM QUALIFICATIONS:
High school diploma/GED or equivalent working knowledge. Two years of work experience in a health care related field or experience managing projects/initiatives, or an equivalent combination of education and experience Three to four years of grievance and appeal work in a health care environment, or an equivalent combination of education and experience. Maintains knowledge of AHCCCS, HCG, and CMS regulations by participating in training, teleconferences, and services.
