Especialista de Querellas y Apelaciones

Especialista de Querellas y Apelaciones

Regular

Exempt

GENERAL DESCRIPTION:

Analyzes, investigates, supports, and answers Grievances, Dental Pre-Service, and Payment Appeals filed by members, insureds, Providers, and/or Non-Part Providers within the time stipulated contractually for both Lines of Business (LOB) and following the terms stated in the contracts established and the rights of Patients and Providers.

ESSENTIAL FUNCTIONS:

• Analyzes, investigates, resolves, and responds to Grievances, Dental Pre-Service, and Payment Appeals, filed by MCS Classicare or MCS Life policyholders, in compliance with Centers for Medicare and Medicaid Services (CMS) regulation, Office of the Commissioner of Insurance (OIC), and internal policies.
• Consults and collaborates with other Departments or Units, Dental Physician reviewers, Delegated Entities, and/or suppliers as part of the analysis, investigation, and support process; validates their responses, assesses root causes, identifies areas of opportunity, and ensures proper collaboration and documentation based on the impacted issue.
• Documents cases and uses the Grievances & Appeals management platform to support analysis and complete the resolution of the case. When required, send notifications to Net Claim system to complete the resolution of dental pre-service appeals.
• Case reconsiderations or member requests must be handled as established by the applicable regulation and due process to CMS contracted Independent Review Entities (IRE - Maximus). Case files must be documented in English during the appeals process, considering the required documentation and timeliness. This process impacts directly, two (2) Stars metrics related to Appeals Timeliness and Appeals Review (Upheld).
• For appeals, in the event a reconsideration or member request is denied and request second level appeal, for MCS Life LOB, complies with the Office of the Commissioner of Insurance (OIC) regulation and submits cases to Independent Review Organizations (IRO). Case files must be documented in English under the appeals process, considering the required documentation and timeliness.
• For Grievances, records, manages, and resolves issues.

o Comply with verbal contact with the insured and/or authorized representative, or provider during the case investigation process to document and categorize the issue presented.

o Review documentation provided by operational areas to ensure proper resolution.

o Resolve grievances according to the timeliness established by regulation (24 hours if expedite or 30 calendar days for standard). Also consider Office of Patient Advocate (OPP) grievances management' timeframes.

o Investigation process includes verbal notices, written notices, RCA, if applicable, within others for proper compliance with process.

• Constant monitoring of grievances and appeals timely management and procedure to avoid impact on 3 Stars metrics related to CTM, Appeals Timeliness, and Appeals Review (Upheld).
• Complies with the delivery of data required by G&A Analysts or immediate Supervisor to complete reports required by Regulatory Agencies, in the established timeframes and as requested (Example: CMS, ASES, OPP, OIC, other Departments, and/or MCS Units).
• Identifies providers and insureds with recurring grievances and informs immediate supervisor for referral and intervention by the appropriate Department(s), e.g., Provider Department, Compliance Department, others.
• Provides training on Grievances and Appeals Policies and Procedures and their impact on the Organization, in the

New Employee Orientation, or as required by the management team.

• If required, participate in meetings that, due to their function, require personnel with expertise in managing

Grievances and Appeals. For example, the Satisfaction Committee, Model of Care (MOC), and others.

• Participate in program review and/or implementation projects, where staff with experience in managing

Grievances and Appeals are required, if needed, e.g., update of PMHS, Beacon, others.

• Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.
• May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.

MINIMUM QUALIFICATIONS:

Education and Experience: Bachelor s degree in Business Administration, Finance, Social Sciences, or Criminal Justice. Minimum of three (3) years of experience in research, auditing, or client/provider service, preferably within the Health Insurance Industry.

OR

Education and Experience: Associate's Degree in Business Administration, Finance, Social Sciences, or Criminal Justice or sixty (60) approved university credits. Minimum of five (5) years of experience inresearch, auditing, or client/provider service, preferably within the Health Insurance Industry.

"Proven experience may be replaced by previously established requirements."

Certifications / Licenses: N/A

Other: Knowledge in Beacon and PMHS preferred.

Languages:
Spanish - Intermediate (writing, conversation, and comprehension)
English - Intermediate (writing, conversation, and comprehension)

“We are an Equal Employment Opportunity Employer and take Affirmative Action to recruit Protected Veterans and Individuals with Disabilities.”