Complaints/Appeals & Grievances Specialist
This position offers the possibility for remote/hybrid work
The Complaints/Appeals & Grievances Specialist has primary responsibility for handling member Appeals and Grievances (A&G) according to State and Federal regulations and time frames, and in accordance with PrimeWest Health policy. The Complaints/Appeals & Grievances Specialist takes direction from the Manager of Quality Management regarding the administration of member State Appeals (Fair Hearings with the State), and A&G. This position also assists with Part C and Part D processes related to Data Validation audits. This individual will maintain strict confidentiality of all sensitive information and will maintain documentation of State Appeals (Fair Hearings with the State) and A&G in accordance with Minnesota Department of Human Services (DHS) and Centers for Medicare & Medicaid Services (CMS) standards. The Complaints/Appeals & Grievances Specialist is responsible for maintaining interdepartmental documentation of communication and relationships with key PrimeWest Health partners as directed by the Manager of Quality Management and Director of Quality & Utilization Management. All duties related to State Appeals (Fair Hearings with the State) and A&G 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.
Educational Requirements and Required Qualifications
1. At minimum, an associate degree or diploma in administrative assistance or two years of experience equivalent to the position requirements
2. Demonstrated knowledge of, and proficiency in, Word, Excel, and Outlook required. Experience in word processing and relational databases is a plus.
3. 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 and written communication skills.
4. 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.
PrimeWest Health is an Equal Opportunity Employer Committed to Diversity, Equity, and Inclusion