Grievance Lead - AlohaCare

Apply on line at http://www.alohacare.org/Careers/Default.aspx

The Company:

AlohaCare is a local, non-profit health plan serving the Medicaid and Medicare dual eligible population. We provide comprehensive managed care to qualifying health plan members through well-established partnerships with quality health care providers and community-governed health centers. Our mission is to serve individuals and communities in the true spirit of aloha by ensuring and advocating access to quality health care for all. This is accomplished with emphasis on prevention and primary care through community health centers that founded us and continue to guide us as well as with others that share our commitment. As Hawaii’s third-largest health plan, AlohaCare offers comprehensive prevention, primary and specialty care coverage in order to successfully build a healthy Hawaii.

The Culture:

AlohaCare employees share a passion for helping Hawaii’s most underserved communities. This passion for

helping and caring for others is internalized and applied to our employees through a supportive and positive work environment, healthy work/life balance, continuous communication and a generous benefits package.

AlohaCare’s leadership empowers and engages its employees through frequent diversity, recognition, community, and educational events and programs. AlohaCare has a strong commitment to support Hawaii’s families and reinforces a healthy work/home balance for its employees. Because AlohaCare values honesty, respect and trust with both our internal and external customers, we encourage open-door, two-way communication through daily interactions, employee events and quarterly all-staff meetings. AlohaCare’s comprehensive benefit package includes low-cost medical, dental, drug and vision insurance, PTO program, 401k employer contribution, referral bonus and pretax transportation and parking program.

These employee-focused efforts contribute to a friendly, team-oriented culture which is positively reflected into the communities we serve.

Position Summary:

The Grievance Leads ensures that response to grievances and appeals is done in a timely, professional, customer-focused manner, and is well documented. Ensures that case documents are audit-ready and grievances and appeals are handled per QUEST Integration, CMS, NCQA, and other accreditation and regulatory requirements and AlohaCare standards.

Primary Duties and Responsibilities:

• Lead continued development and implementation of an organizational grievance training program regular training of departments and individual staff as required to assist in ensuring regulatory compliance.
• Identifies trends and with Grievance and Appeals Manager in improving operational processes that impact on member satisfaction and complaint numbers.
• Provides guidance to Junior Grievance Coordinators and Grievance Coordinators in the review, research, monitoring and routing of complaints, grievances and appeal cases to appropriate personnel to assure timely, corrective and documented resolution is achieved.
• Manages challenging and/or complex grievances and appeals that require escalation and continued evaluation.
• Checks Complaints Tracking Module (CTM) daily (including weekends) and take appropriate steps to resolve any CTM complaints.
• Reviews, researches and directs complaints, grievances and appeal cases to appropriate personnel, and follows up to ensure that resolution has occurred, documentation is complete, required timeframes are met, and proper written communication of the decision has occurred. In most cases, prepares the written communication of the decision in plain written language. Coordinates additional follow up activities with appropriate department managers and/or leads and tracks to conclusion.
• Monitors grievance and appeal logs extracted from Bizagi using the Health Catalyst Tools, in a timely manner for both lines of business. This includes tracking dispositions and maintaining timeliness of resolution as required by state and federal mandates.
• Conducts monthly quality assurance check of cases to ensure compliance to AlohaCare policies, state and federal laws, rules and regulations regarding Grievance and Appeals processing.
• Maintains electronic files of all documentation, and appropriate follow up documentation in member and provider memo screens, or other computer system modules or databases as per current workflows.
• Ensures that all information to providers, members, employees and other appropriate persons is accurate, consistent and customer sensitive.
• When needed for specific types of grievances or appeals, prepares summaries for committee review, documents meeting discussions, and communicates decision in writing.
• Acts as back-up for G&A Manager in preparing all Grievance & Appeals reports, as required by QUEST Integration, CMS, or other regulatory agencies per format and timeframes specified. Coordinates with G&A Manager to ensure that report drafts are prepared in advance with sufficient time for internal management review.
• If requested, participates in internal committee and interdisciplinary meetings, reporting recent activity and analysis of trends, and makes recommendations for problem resolution and performance improvement.
• Responsible to maintain AlohaCare’s confidential information in accordance with AlohaCare policies, state and federal laws, rules and regulations regarding confidentiality. Employees have access to AlohaCare data based on the data classification assigned to this job title.
• Other duties as required.

Required Qualifications:

Associate’s degree or equivalent combination of education and experience

2 - 3 years of related work experience

Strong verbal and written communication in English.

Requires operation of general office equipment to include: PC, fax/copy machine and ACD Midel Phones and proficient knowledge of Microsoft Office tools

Achieves results, builds trust, communicates effectively, customer and quality focused.

Ability to multi-task, adapt to changing priorities, manage a diversity of high priority projects in a fast-paced environment.

Ability to organize and coordinate information with multiple departments and different staff levels, including management

Strong problem solving and customer service skills

Self-Initiative

Experience with utilizing multiple databases

Engages in Process Improvement

Preferred Qualifications:

Experience in conducting training

Health plan experience

Knowledge of Medicaid, Hawaii QUEST Integration Program, and/or Medicare

Grievance & Appeal processing experience

Bachelor’s Degree

Physical Demands/Working Conditions:

Inside working conditions

No environmental hazards

Ability to conduct training; potentially with audiovisual presentations

Sedentary Work: Exerting up to 20 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time.

Salary Range: $19.75 - $26.00 an hour

AlohaCare is committed to providing equal employment opportunity to all applicants in accordance with sound practices and federal and state laws. Our policy prohibits discrimination and harassment because of race, color, religion, sex (including gender identity or expression), pregnancy, age, national origin, ancestry, marital status, arrest and court record, disability, genetic information, sexual orientation, domestic or sexual violence victim status, credit history, citizenship status, military/veterans status, or other characteristics protected under applicable state and federal laws, regulations, and/or executive orders.