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Serve as patient advocate when a patient has a grievance, following the System policy and procedure. In-training as a Licensed Professional Counselor (LPC-IT), Marriage and Family Therapist Training License (MFT-TL), Social Worker Training Certificate (SWTC), Advance Practice Social Work (APSW) or equivalent in state practicing.
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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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Principles, practices, and techniques of human resources in a public agency setting, including recruitment, selection, equal employment opportunity, and employee onboarding; job analysis and classification; compensation and benefit analysis and administration; employee relations, including the interpretation of laws, regulations, policies, and procedures; public sector labor relations, including effective negotiation techniques, grievance resolution methods, and progressive discipline.
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Grievance and Appeals experience. Documents and logs appeal/grievance information on relevant tracking systems and mainframe systems. Grievance and Appeals experience. Location: This is a virtual position and prefer candidates reside within 50 miles of an Elevance Health PulsePoint location.
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Identify and address specialty / flagged cases and follow appropriate processes for different types of cases Communicate with a diverse set of internal and external clientele to achieve excellent results in the areas of complaint and grievance handling, compliance, documentation and enhancement of the member experience.
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American Red Cross Professional Rescue is required within thirty (30) days of date of hire. Report and document suspected cases of physical, sexual abuse and/or neglect according to the law in the state of employment and according to System policy and procedure.
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Identifies Grievance and Appeals trends and implements process improvements as needed. Assists in the daily requests for Grievance and Appeals. Identifies Grievance and Appeals trends and implements process improvements as needed.
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Assists with complex investigation and multi-forum complaints and grievance matters, including Whistleblower/Internal Audit, Equal Opportunity, and Title VII of the Civil Rights Act, etc., and coordinates with internal and external resources on litigation and pre-litigation matters.
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