Manage, research and respond to QUEST Integration inquires, complex complaints, grievances and appeals relating to all aspects of health plan coverage consistent with contract, regulatory and/or accreditation requirements (e.g. State, DHS, CMS, NCQA).
Bachelor's degree in Business Administration or related field (ex. communications, statistics, political science, English) and four (4) years of related work experience (ex. analyst, investigator, researcher, paralegal or closely related occupations which demonstrate analytical ability and experience handling complex customer appeals/complaints); or an equivalent combination of education and related work experience.
Demonstrated experience in handling complex situations requiring problem identification and resolution.
Effective verbal and written communication skills; must be perceptive and empathetic to concerns of members and providers.
Strong planning and organization skills.
Intermediate email and Microsoft Word skills
Basic Excel and Powerpoint skills
Duties and Responsibilities
A. Conducts critical analysis of highly complex and sensitive member and provider inquiries, complaints, grievances and appeals for QUEST Integration, and applies internal policies and procedures, contractual provisions, and regulatory requirements. Secures information from internal and external resources to resolve issues. Functions as a liaison with providers, members and internal decision makers in representing HMSA objectives, goals and expectations for meeting contractual, regulatory, and accreditation requirements. Negotiates/resolves sensitive issues with internal and external parties. Negotiates fees on behalf of members for non-covered or non-participating provider services in addition to soliciting claims and other related medical information from providers in order to resolve member inquiries. Takes all facts and research from internal and external resources and presents a full explanation of the member's or provider's position and concerns to management and decision makers. Triages cases to resolve them upon initial inquiry to best service the member as well as minimize the number of cases escalated. Work in partnership with designated Quality Management department staff for clinical review.
B. Participates on various cross departmental committees and other internal meetings to identify, clarify, research and resolve inquiries and issues. Identify required changes to policies and procedures based on case resolutions, statutory or regulatory changes, or accreditation requirements. Propose changes to management based on identification and analysis. Analyzes and identifies issues that require multiple department efforts to resolve, then coordinates discussions and meetings to develop process to resolve those issues. Presents recommendations to internal committees and executive management, and assists with the implementation of resulting decisions for change/resolution. Assists supervisor/manager in responding to internal investigations, reviews and audits; regulatory inquiries; and accreditation related audits. Assists internal customers with complex member/physician inquiries.
C. Produce complaint, grievance and appeal reports/analysis for HMSA QUEST in coordination with the Member Advocacy and Appeals and QUEST Customer Relations staff.
Ensures ongoing reporting (i.e. quarterly or more frequent) to appropriate internal committees as required.
Ensures ongoing reporting (i.e. quarterly or more frequent) to State, CMS or other regulatory areas by coordinating completions and/or submissions as required.
Supports HMSA QUEST Integration Administration with deliverables as defined in the Annual Reporting and Monitoring Activities calendar issued by DHS. Serve as
Coordinate or serve as Project Coordinator as needed for QUEST Integration Administration Activities for grievances and appeals
D. Evaluates/monitors work performance of staff and reports progress, barriers and solutions. Collaborates with other departments to improve processes and workflows across departments. Facilitates cross-departmental discussions and actions to promote effectiveness and efficiencies
E. Assists supervisor and manager in managing resources, workloads and represents the department in various corporate activities, etc. Provides training for department and other departments on policies and procedures relating to regulatory and accreditation requirements; leads discussions and provides training on problem identification and resolution.
F. Identifies member problems, member education needs or trends and report these to manager, as well as recommend resolution. Takes a proactive role in digesting and communicating any new regulation, standard, business change, etc. affecting the member advocacy and/or grievance and appeals process. Assists in the coordination of changes among departments. Assists in determining internal and external impacts.
G. Finalizes presentations of internal and external appeals reviews, including performing quality assurance of case documents.
H. Other Duties/Functions: Assists in special projects, analyzes and documents trends for supervisor's review, and performs other duties as assigned.