Complaints/Appeals & Grievances Coordinator
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 works to administer member State Appeals (State Fair Hearings), A&Gs, and Part C and Part D processes related to data validation audits and facilitates and ensures that PrimeWest Health's A&Gs system complies with Minnesota Department of Human Services (DHS), Centers for Medicare & Medicaid Services (CMS), and National Committee for Quality Assurance (NCQA) requirements. The Complaints/Appeals & Grievances Coordinator 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 position maintains documentation of State Appeals and A&Gs according to DHS and CMS standards and is responsible for maintaining interdepartmental communication documentation and 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.
Educational Requirements and Required Qualifications
At minimum, an associate degree or diploma in administrative assistance or two years of experience equivalent to the position requirements.
Two or more years of experience with Medicaid 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.