Complaints/Appeals & Grievances Coordinator

at  PrimeWest Health

Are you passionate about making a difference in healthcare? As a Complaints/Appeals & Grievances Coordinator at PrimeWest Health, you’ll be at the forefront of ensuring our members receive the best care possible. You’ll handle member Appeals and Grievances (A&Gs) with precision and compassion, adhering to State and Federal regulations and PrimeWest Health policies.

In this dynamic role, you’ll:

• Administer member State Appeals (Fair Hearings with the State) and manage Part C and Part D processes related to data validation audits.
• Facilitate our A&Gs system, ensuring compliance with Minnesota Department of Human Services (DHS), Centers for Medicare & Medicaid Services (CMS), and National Committee for Quality Assurance (NCQA) requirements.
• Present and analyze quarterly reports for the PrimeWest Health Quality & Care Coordination Committee (QCCC) and required State and Federal entities.
• Maintain meticulous documentation of State Appeals and A&Gs, ensuring all records meet DHS and CMS standards.
• Foster interdepartmental communication and build strong relationships with key PrimeWest Health partners.

You’ll work closely with the PrimeWest Health Chief Senior Medical Director and under the guidance of the Manager of Quality Management and/or Director of Quality & Utilization Management. Your role is crucial in maintaining the confidentiality of all sensitive information.

• Educational Requirements and Required Qualifications
• At minimum, an associate degree in administrative assistance, health care, and/or nursing, or two years of experience equivalent to the position requirements.
• Two or more years of experience with Medicaid (Medical Assistance) Managed Care A&Gs is preferred.
• Demonstrated knowledge of, and proficiency in, Word, Excel, and Outlook required.
• Flexibility and ability to handle multiple tasks. Demonstrated organizational skills and attention to detail. Ability to work effectively with a variety of people both within and outside of the organization. Good verbal, written, and interpersonal communication skills.
• Ability to sit at a desk or computer station most of the time. Ability to occasionally lift and/or carry such articles as file folders and small boxes up to 30 pounds.

The Complaints/Appeals & Grievances Coordinator has primary responsibility for handling member Appeals and Grievances (A&Gs) in accordance with State and Federal regulations and time frames and PrimeWest Health policy. The Complaints/Appeals & Grievances Coordinator administers member State Appeals (Fair Hearings with the State), A&Gs, and Part C and Part D processes related to data validation audits and facilitates PrimeWest Health’s A&Gs system, ensuring it complies with Minnesota Department of Human Services (DHS), Centers for Medicare & Medicaid Services (CMS), and National Committee for Quality Assurance (NCQA) requirements. This position presents and analyzes quarterly A&G and State Appeal reports for the PrimeWest Health Quality & Care Coordination Committee (QCCC) as well as for required State and Federal entities. This Complaints/Appeals & Grievances Coordinator maintains documentation of State Appeals and A&Gs according to DHS and CMS standards and is also responsible for maintaining documentation of interdepartmental communication and facilitating relationships with key PrimeWest Health partners. All State Appeal and A&G-related duties and responsibilities are performed in collaboration with the PrimeWest Health Chief Senior Medical Director and under the direction of the Manager of Quality Management and/or Director of Quality & Utilization Management. This individual must maintain strict confidentiality of all sensitive information.

• Reporting Accountability

This position is responsible for meeting the following regulatory, contractual, or other requirements on behalf of PrimeWest Health:

• Complete appropriate quality oversight of required regulatory reports for DHS and CMS and provide insight and consultation to the Manager of Quality Management when changes are indicated and/or corrective action needs to occur
• Ensure compliance with all regulatory and contractual requirements related to the Quality & Utilization Management department
• Act as lead on all regulatory and accreditation audits
• Act as lead on all regulatory meetings and workgroups related to A&Gs
• Act as lead on reporting and presenting all A&G data to QCCC
• ROLE AND KEY RESPONSIBILITIESAssist the Manager of Quality Management and other PrimeWest Health staff in the following as needed:
• NCQA standards related to Appeals and Grievances. This includes ensuring policy compliance, writing reports, and maintaining current knowledge of NCQA technical specifications.
• Conduct annual review of policies related to A&Gs. Maintain current knowledge of DHS, CMS, and NCQA regulatory requirements to ensure compliance.
• Act as lead liaison to workgroups pertaining to A&Gs for external and internal stakeholders.
• Provide support to the Manager of Quality Management and Director of Quality & Utilization Management as needed, including assisting with report and application submissions, answering and making phone calls, making copies, faxing documents, constructing letter/documents, and preparing mailings
• Maintain current knowledge of complaints and A&G regulatory guidelines and facilitate the process for updating policies, procedures, workflows, templates, etc.
• Assist with data entry and retrieval; develop graphs and charts as needed
• Record meeting minutes as requested
• Attend State Appeals/meetings as requested
• Provide backup to the Complaints/Appeals & Grievances Specialist with respect to submitting quarterly electronic reports for oral/written A&Gs to the State
• Prepare, facilitate, and participate in annual data validation reports for measures related to A&Gs per CMS requirements. This includes keeping abreast of regulatory changes and communicating the changes to applicable staff and updating policies, procedures, and workflows as necessary.
• Handle State Appeals and A&Gs as necessary to ensure that all concerns are responded to and resolved appropriately. Maintain diplomatic approach to investigating member Grievances.
• Check systems for expedited A&G requests on weekends and holidays on a rotating basis
• Assist with office coverage for mail on a rotating basis
• Work closely with the Quality Specialist regarding quality of care issues
• Stay current on all new legislation and statutes as well as amendments to facilitate compliant documentation and handling and reporting of A&G processes
• Organize State Appeals, A&Gs, and complaints and provide a summary of quarterly activities to QCCC
• Increase member satisfaction by providing professional and accurate responses to complaints regarding benefits, eligibility, authorization, claims, and pharmacy issues; ensure that all concerns are responded to and resolved appropriately and expeditiously
• Schedule Grievance Review Workgroup meetings when necessary
• Update A&G Confluence page as needed
• General PrimeWest Health Responsibilities
• Abide by the PrimeWest Health Code of Conduct
• Comply with all PrimeWest Health policies and procedures
• Comply with the Health Insurance Portability and Accountability Act (HIPAA) and all other privacy laws
• Be familiar with building safety procedures and alert maintenance if something requires attention
• Keep public areas of the department and office neat and clean
• Conduct other responsibilities and activities as needed and assigned
• Professional Competencies
• Ability to make decisions independently with minimal supervision
• Public speaking skills
• Strong writing skills
• Organization and time management skills
• Appropriate Licensure and Certification Requirements – N/A
• Collaborative Efforts with Other Departments
• Administration
• Business IT & Claims Administration
• Care & Population Health Management
• Corporate Compliance & Auditing
• Information Systems & Technology
• Member & Provider Services
• Operations
• Pharmacy Management
• Supervision – N/A

THIS POSITION DESCRIPTION IS NOT TO BE CONSTRUED AS AN EXHAUSTIVE STATEMENT OF ESSENTIAL FUNCTIONS OR RESPONSIBILITIES.

Alexandria, Minnesota – This position offers the possibility for hybrid work
PrimeWest Health will accept résumés for this position until filled. No phone inquiries please. Employment to begin as soon as possible

In this dynamic role, you’ll:

• Administer member State Appeals (Fair Hearings with the State) and manage Part C and Part D processes related to data validation audits.
• Facilitate our A&Gs system, ensuring compliance with Minnesota Department of Human Services (DHS), Centers for Medicare & Medicaid Services (CMS), and National Committee for Quality Assurance (NCQA) requirements.
• Present and analyze quarterly reports for the PrimeWest Health Quality & Care Coordination Committee (QCCC) and required State and Federal entities.
• Maintain meticulous documentation of State Appeals and A&Gs, ensuring all records meet DHS and CMS standards.
• Foster interdepartmental communication and build strong relationships with key PrimeWest Health partners

You’ll work closely with the PrimeWest Health Chief Senior Medical Director and under the guidance of the Manager of Quality Management and/or Director of Quality & Utilization Management. Your role is crucial in maintaining the confidentiality of all sensitive information.

• Educational Requirements and Required Qualifications
• At minimum, an associate degree in administrative assistance, health care, and/or nursing, or two years of experience equivalent to the position requirements.
• Two or more years of experience with Medicaid (Medical Assistance) Managed Care A&Gs is preferred.
• Demonstrated knowledge of, and proficiency in, Word, Excel, and Outlook required.
• Flexibility and ability to handle multiple tasks. Demonstrated organizational skills and attention to detail. Ability to work effectively with a variety of people both within and outside of the organization. Good verbal, written, and interpersonal communication skills.
• Ability to sit at a desk or computer station most of the time. Ability to occasionally lift and/or carry such articles as file folders and small boxes up to 30 pounds

This position is responsible for meeting the following regulatory, contractual, or other requirements on behalf of PrimeWest Health:

• Complete appropriate quality oversight of required regulatory reports for DHS and CMS and provide insight and consultation to the Manager of Quality Management when changes are indicated and/or corrective action needs to occur
• Ensure compliance with all regulatory and contractual requirements related to the Quality & Utilization Management department
• Act as lead on all regulatory and accreditation audits
• Act as lead on all regulatory meetings and workgroups related to A&Gs
• Act as lead on reporting and presenting all A&G data to QCCC
• ROLE AND KEY RESPONSIBILITIESAssist the Manager of Quality Management and other PrimeWest Health staff in the following as needed:
• NCQA standards related to Appeals and Grievances. This includes ensuring policy compliance, writing reports, and maintaining current knowledge of NCQA technical specifications.
• Conduct annual review of policies related to A&Gs. Maintain current knowledge of DHS, CMS, and NCQA regulatory requirements to ensure compliance.
• Act as lead liaison to workgroups pertaining to A&Gs for external and internal stakeholders.
• Provide support to the Manager of Quality Management and Director of Quality & Utilization Management as needed, including assisting with report and application submissions, answering and making phone calls, making copies, faxing documents, constructing letter/documents, and preparing mailings
• Maintain current knowledge of complaints and A&G regulatory guidelines and facilitate the process for updating policies, procedures, workflows, templates, etc.
• Assist with data entry and retrieval; develop graphs and charts as needed
• Record meeting minutes as requested
• Attend State Appeals/meetings as requested
• Provide backup to the Complaints/Appeals & Grievances Specialist with respect to submitting quarterly electronic reports for oral/written A&Gs to the State
• Prepare, facilitate, and participate in annual data validation reports for measures related to A&Gs per CMS requirements. This includes keeping abreast of regulatory changes and communicating the changes to applicable staff and updating policies, procedures, and workflows as necessary.
• Handle State Appeals and A&Gs as necessary to ensure that all concerns are responded to and resolved appropriately. Maintain diplomatic approach to investigating member Grievances.
• Check systems for expedited A&G requests on weekends and holidays on a rotating basis
• Assist with office coverage for mail on a rotating basis
• Work closely with the Quality Specialist regarding quality of care issues
• Stay current on all new legislation and statutes as well as amendments to facilitate compliant documentation and handling and reporting of A&G processes
• Organize State Appeals, A&Gs, and complaints and provide a summary of quarterly activities to QCCC
• Increase member satisfaction by providing professional and accurate responses to complaints regarding benefits, eligibility, authorization, claims, and pharmacy issues; ensure that all concerns are responded to and resolved appropriately and expeditiously
• Schedule Grievance Review Workgroup meetings when necessary
• Update A&G Confluence page as needed
• General PrimeWest Health Responsibilities
• Abide by the PrimeWest Health Code of Conduct
• Comply with all PrimeWest Health policies and procedures
• Comply with the Health Insurance Portability and Accountability Act (HIPAA) and all other privacy laws
• Be familiar with building safety procedures and alert maintenance if something requires attention
• Keep public areas of the department and office neat and clean
• Conduct other responsibilities and activities as needed and assigned
• Professional Competencies
• Ability to make decisions independently with minimal supervision
• Public speaking skills
• Strong writing skills
• Organization and time management skills
• Appropriate Licensure and Certification Requirements – N/A
• Collaborative Efforts with Other Departments
• Administration
• Business IT & Claims Administration
• Care & Population Health Management
• Corporate Compliance & Auditing
• Information Systems & Technology
• Member & Provider Services
• Operations
• Pharmacy Management
• Supervision – N/