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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.
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Prepares reports on grievance and appeals as required by regulatory agencies, NCQA standards, and Plan management. Prepares and maintains case files and database for appeals and grievances in accordance with SHP, DHS, CMS, and DMHC requirements and NCQA accreditation standards.
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Job Description :Title: Grievance/Appeals Analyst ILocation: This position will work a hybrid model (remote and office). The Grievance/Appeals Analyst I is an entry level position in the Enterprise Grievance & Appeals Department that reviews, analyzes and processes non-complex pre service and post service grievances and appeals requests from customer types (i.e. member, provider, regulatory and third party) and multiple products (i.e. HMO, POS, PPO, EPO, CDHP, and indemnity) related to clinical and non clinical services, quality of service, and quality of care issues to include executive and regulatory grievances.
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The UMQM Nurse shall also participate in Utilization Management related activities with the Appeals and Grievance Department as well as the Compliance Department to assure that the quality compliance is being met for NCQA, state and federal regulatory requirements.
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Collaborate with internal departments as necessary (Customer Service Center, Provider Network, Claims, Utilization Management, Pharmacy) to ensure the timely resolution of all appeals and grievances.
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Uses critical thinking and decision making to correctly identify and assign the appeal/grievance type to ensure compliance with the regulations outlined by the North Carolina Department of Insurance (NCDOI), the National Committee for Quality Assurance (NCQA), the Department of Labor (ERISA) and the Centers for Medicare and Medicaid Services (CMS.
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Identifies Grievance and Appeals trends and implements process improvements as needed. Assists in the daily requests for Grievance and Appeals. Preferred: Knowledge of NCQA, CMS, DMHC, DHCS, California Health and Safety Codes, and Milliman, Care Guidelines.
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We are seeking a dynamic Clinical Reviewer will be responsible for performing clinical and administrative reviews within the Grievance and Appeals department, ensuring accurate administration of benefits, execution of clinical policy, timely access to appropriate levels of care and provision of payment for services that have already been rendered.
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Is an entry level position in the Enterprise Grievance & Appeals Department that reviews, analyzes and processes non-complex pre service and post service grievances and appeals requests from customer types (i.e. member, provider, regulatory and third party) and multiple products (i.e. HMO, POS, PPO, EPO, CDHP, and indemnity) related to clinical and non clinical services, quality of service, and quality of care issues to include executive and regulatory grievances.
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The Grievance & Appeals Analyst conducts and documents thorough investigations of all grievance, complaints, and appeal case types, communicating resolution to members and clients in accordance with all state, regulatory, and National Committee Quality Assurance (NCQA) requirements.
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Assist in the development of internal physician advisors and provide support in developing solutions for complex cases, in the authorization and denial of services, and in the grievance and appeals process.
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Coordinate the workflow and operations of two units within the grievance and appeals department, commercial and Government Programs. Manage the daily work of administrative grievance and appeals staff to ensure adherence to quality standards, deadlines, and proper procedures.
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Manage assigned member appeals and grievance cases from documentation, to investigation, and through resolution, ensuring the final disposition of a member’s appeal or grievance is compliant with the regulatory requirements set-forth by NCQA, DOI, CMS, DOL and any state or federal specific regulations that apply.
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The file review components of the URAC and NCQA accreditations are must pass items to achieve the accreditation. Utilizes guidelines and review tools to conduct extensive research and analyze the grievance and appeal issue(s) and pertinent claims and medical records to either approve or summarize and route to nursing and/or medical staff for review.
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The grievance and appeal work is subject to applicable accreditation and regulatory standards and requirements. Analyzes and renders determinations on assigned non-complex grievance and appeal issues and completion of the respective written communication documents to convey the determination.
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grievance appeals and ncqa jobs
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