JOB DESCRIPTION
Title: Manager, Appeals & Grievances RN- REMOTE

Department: Quality Management & Health Plan Compliance

Reports To: Director

Location: 5 Penn Plaza/hybrid

Education: Bachelor’s Required, Masters Preferred

License: RN License Required

Job Type: Full Time Employee

JOB SUMMARY

Responsible to manage the appeals and grievances program. Ensure compliance with Department of

Defense/Defense Health Agency regulations (DoD / DHA), TRICARE policy and Federal law. Ensure responses to appeals, grievances, executive inquiries and escalated complaints are completed in a well-documented, professional, timely and efficient manner. Ensure accurate monitoring, tracking and reporting are performed.

Develop corrective action plans as indicated. Functions as primary liaison with all departments and external review agencies. Implement, monitor and maintain program standards, requirements, policies and procedures. Provide oversight and reporting of the Plan's appeals, grievances, and executive inquiries and escalated complaints to ensure ongoing compliance, beneficiary and provider satisfaction.

RESPONSIBILITIES

APPEALS & GRIEVANCE PROGRAM MANAGEMENT: Responsible to manage the Plan's appeals and grievances program. Ensure compliance with Department of Defense/Defense Health Agency regulations

(DoD / DHA), TRICARE policy and Federal law. Ensure responses to appeals, grievances, executive inquiries and escalated complaints are completed in a well-documented, professional, timely and efficient manner.

Ensure accurate monitoring, tracking and reporting are performed. Develop corrective action plans as indicated. Function as primary liaison with all departments and external review agencies. Implement, monitor and maintain program standards, requirements, policies and procedures. Provide oversight and reporting of the Plan's appeals, grievances, and executive inquiries and escalated complaints to ensure ongoing compliance, beneficiary and provider satisfaction.

REPORTING & DOCUMENTATION MANAGEMENT: Receive, investigates and respond to all beneficiary and provider, appeals, grievances, escalated complaints and executive inquiries within DHA required turnaround times (TATs) and Plan requirements. Draft response letters to providers and beneficiaries. Prepare file submissions to Kepro and DHA for expedited appeals, second level appeals, grievances, executive inquiries and other cases as required. Conduct medical record reviews and requests as indicated for all second level appeal determinations. Research document and prepare written reports, responses and summaries as required including corrective action plans and recommendations/ actions for resolution. Develop and maintain standard templates. Design and prepare reports, including data analysis and recommendations for improvement. Implement TRICARE manual changes to USFHP policies and procedures and update as necessary to ensure compliance with DHA and TRICARE requirements. Maintain paper and electronic file integrity adhering to confidentiality requirements.

COMMITTEE MEETINGS AND PARTICIPATION: Participate in DHA audits, internal committee and management meetings, reporting recent activity and analysis of trends with recommendations for problem resolution and performance improvement as indicated. Provide and present data as required for medical management, quality committee, and other meetings as requested. Report recent activity and analysis of trends on a monthly, quarterly and annual basis.

OVERSIGHT: Manage oversight of appeals and grievances sections for DHA audits and draft responses to inquiries by DHA. Manage and monitor all second level appeals and oversight for third party vendor (i.e.,

Toney Health Care, Orthonet, Magellan and Maxor) initial/ first level appeals and grievances process to include review of monthly reporting metrics and implementation of corrective action plans where indicated.

Compile, analyze and report data on a monthly, quarterly and annual basis to committee meetings. Review, research and monitor appeals, grievances and escalated complaints to ensure a documented and proper resolution occurs within the required TRICARE Operations Manual (TOM) 2015 processing standard TATs and Plan requirements. Provide guidance to vendor staff to acquire necessary documentation and ensure executive inquiries, grievances, escalated complaints and appeal cases are appropriately routed and documented to ensure a timely and comprehensive resolution is achieved. Develop and maintain compliance with USFHP policies and procedures. Coordinate with Manager of Health Plan Compliance to assist with vendor audits relating to subject matter in order to ensure compliance under contract in addition to regulatory or accreditation requirements. Collaborate with other departments to support oversight, compliance, quality audits and investigations for fraud and abuse. Track, analyze and report findings on a monthly, quarterly and annual basis.

APPEALS MANAGEMENT:

Provide instruction and oversight of vendor staff assigned to handle first-level appeals, like specialty appeals, reconsideration reviews and timely forwarding of all second-level appeals to the Plan. Provide guidance to staff with respect to Plan benefit and documentation necessary to complete second level appeal review.

Ensure all appeals are completed in accordance with TRICARE processing standards, (within (2) business days for all expedited cases, 95% of standard cases are completed within 30 days and 100% of standard cases completed within 60 days).

Review all second-level appeals referred to the Plan. Second level medical necessity appeals expedited,

(concurrent inpatient and pre-service) and standard / routine appeals meeting all procedural requirements are reviewed with CMO and forwarded to the TRICARE Quality Monitoring Contractor (TQMC) KePRO / DHA in accordance with the requirements as outlined in the TOM, Ch.12. Factual appeals denied as (non- covered, experimental) meeting all procedural requirements are discussed with CMO prior to DHA submission. Log, track, monitor and provide reporting on all second level cases sent to KePRO / DHA, on a monthly, quarterly and annual basis.

All Network appeals are handled in a like manner and processed in accordance with TRICARE TATs and the provider's contract. Second level / like specialty reviews are referred to THC for review as indicated. All appeals are processed accordance with timelines as outlined in the TOM Ch. 12. Maxor Pharmacy appeal review upholding the initial denial/ first level appeal are handled in an expedited manner according to the

CMO's review and decision. Denial letters are drafted for CMO signature using appropriate denial language and sent to provider and member with administrative assistance.

Factual denial letters for the Plan's uphold of non-covered benefit/ LDT denial are produced in accordance with the TOM, signed by Senior Appeals Manager with copies to MD, member and provider. Appeals and

Grievances Manager handles administrative denials for timely filing, letters and responses to completion.

Collaborates with UR and Claims Manager/Senior Manager where necessary to achieve timely appeal resolutions, reprocess overturns within 21 days and assist with resolving DRG cases, within the standard timeline above. All cases are closed out in SalesForce and entered on tracking log for reporting.

GRIEVANCE MANAGEMENT:

Provide instruction and oversight of vendor staff assigned to handle grievance process to include appropriate identification and timely forwarding to the plan. Receive, track, monitor and report all written complaints received by (paper, mail, e-mail, fax or portal) Potential Quality Issues (PQIs) are identified through grievance investigation and referred to clinical quality for PQI investigation. Fraud and abuse are considered in all grievance investigations and referred to quality and compliance as indicated. Appeal issues are reviewed under the appeals process and tracked accordingly. Collaborate with all departments as necessary to provide guidance and fully investigate, resolve and respond to grievances within the required

TRICARE TATs, (100% completed as final or interim response issued within 30 calendar days; 95% of cases completed as final within 60 calendar days) Issue interim response when appropriate to include explanation of delay and estimated date of completion. Final written response provides for result of investigation, how to request additional information and / or second administrative review. All cases are closed out in

Salesforce and entered on tracking log for reporting.

EXECUTIVE INQUIRY MANAGEMENT: Provide instruction and oversight of vendor staff who receive executive inquiries to include appropriate identification and timely forwarding to the plan. Receive, track, monitor and report all executive inquiries. Potential Quality Issues (PQIs) are identified through executive inquiry investigation and referred to clinical quality for PQI investigation. Fraud and abuse are considered in all executive inquiry investigations and referred to quality and compliance as indicated. Appeal matters are reviewed under the appeals process and tracked accordingly. Collaborate with all departments as necessary to provide guidance and fully investigate, resolve and respond to executive inquiries within the required

TRICARE TATs, (100% USFHP Executive inquiry initial response within (2) days; 85% completed as final within (10) calendar days; 100% of cases completed as final within (30) calendar days) Issue written acknowledgement of receipt to sender on same day received. Issue interim written response to sender on cases that cannot be fully resolved within (10) calendar days. Final written response provides for complete result and final outcome of investigation. All cases are closed out in Salesforce and entered on tracking log for reporting.

ESCALATED COMPLAINT MANAGEMENT: Collaborate with Customer Service to provide guidance and fully investigate escalated complaints received through Salesforce as unresolved by Customer Service personnel.

Receive, track and monitor escalated complaints, Provide reporting metrics to management as required.

Review all complaints for appropriate identification and timely forwarding. Identify Potential Quality Issues

(PQIs) through investigation and refer to clinical quality for PQI investigation as indicated. Fraud and abuse issues are referred to quality and compliance as indicated. Appeal matters are reviewed under the appeals process and tracked accordingly. Collaborate with other departments as necessary to provide guidance, fully investigate and resolve escalated complaints in accordance with USFHP requirements. Final response shall address all matters cited within the complaint. Communication of result may be provided back to customer service through salesforce for provider / member, or may be issued directly to sender. All cases are closed out in Salesforce and entered on tracking log for management reporting purposes.

SUPERVISORY:

• One administrative program coordinator
• One clinical appeals/grievance review nurse (RN)

Performs other duties, projects and actions as assigned.

EXPERIENCE

Three to five years of healthcare appeals, utilization review, clinical nursing, case/disease management and / or quality improvement. Managed health plan appeals / denials management or healthcare operations (i.e., quality, risk management, audit, etc) experience preferred.

Skills/Competencies

• Detail-oriented with excellent organizational and management skills.
• Ability to meet deadlines and adjust to changes in policies, procedures, and priorities.
• Ability to work well both independently and with others.
• Strong analytical, investigation and problem solving skills.
• Ability to read, analyze, and interpret governmental regulations.
• Ability to ensure organizational compliance with all required rules, policies and procedures.
• Excellent oral, written and interpersonal communication skills. Ability to write responses, summaries, reports, policies, procedures and business correspondence.
• Ability to organize and coordinate information with multiple departments and different staff levels, including management.
• Ability to effectively research, present information and respond to inquiries from beneficiaries, providers, congress and regulatory agencies, as necessary.
• Thorough knowledge of all levels of appeal, grievances/ complaints, executive inquiries.
• Interpretation of Plan, TRICARE, Medicare and / or commercial health insurance criteria in benefit determinations, denials and appeals.
• Level of care / intensity of care determinations and appropriate sequencing of care.
• Thorough knowledge of health care industry appeals and grievance/ complaint procedures and practice.
• Ability to act as subject matter expert (SME) in appeals and grievances to ensure URAC/ NCQA accreditation and regulatory requirements.
• Microsoft Office including strong technical knowledge of Excel and PowerPoint.
• Database management.
• Decision making: o interpretation of TRICARE policy, DHA requirements and regulatory standards o investigation, analysis and recommendations for process changes and/or improvement based on findings o Interpretation of Plan, TRICARE and commercial health insurance criteria in benefit determinations, denials and appeals

Education/Certifications/License

• Current and unrestricted NY state RN license required
• BA, BS, or BSN required
• MSN, MS, MBA or MPH preferred

SVCMC IS AN EQUAL OPPORTUNITY EMPLOYER - ALL QUALIFIED APPLICANTS WILL RECEIVE CONSIDERATION FOR EMPLOYMENT WITHOUT REGARD TO RACE, COLOR, RELIGION, SEX, SEXUAL ORIENTATION, GENDER IDENTITY, NATIONAL ORIGIN, DISABILITY OR VETERAN STATUS.

Job Type: Full-time

Pay: $100,000.00 - $105,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Health insurance
• Life insurance
• Paid time off
• Professional development assistance
• Tuition reimbursement
• Vision insurance

Schedule:

• Day shift
• Monday to Friday
• No weekends

Experience:

• Healthcare appeals: 5 years (Required)
• Utilization review: 5 years (Required)

Work Location: Remote

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