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The Appeals and Grievance Specialist is responsible for managing and resolving appeals and grievances in accordance with contractual, regulatory, and accreditation standards. This role involves gathering and analyzing information, conducting research, and preparing comprehensive, timely responses to ensure fair and compliant outcomes. The Specialist communicates directly with participants to obtain necessary details, explain determinations, and provide support throughout the appeals process. This position also represents AgeWays during external communications with participants, others relevant to appeals/grievance filings, and in administrative hearing proceedings.

Duties Include:

+ The Appeals and Grievance Specialist is responsible for managing and resolving appeals and grievances in accordance with contractual, regulatory, and accreditation standards. This role involves gathering and analyzing information, conducting research, and preparing comprehensive, timely responses to ensure fair and compliant outcomes. The Specialist communicates directly with participants to obtain necessary details, explain determinations, and provide support throughout the appeals process. This position also represents AgeWays during external communications with participants, others relevant to appeals/grievance filings, and in administrative hearing proceedings.

+ Conduct thorough investigations of participant grievances to ensure concerns are addressed promptly, fairly, and in compliance with contractual, regulatory, and accreditation requirements. Interview or correspond with participants, caregivers, providers, and other stakeholders as needed to gather facts and clarify concerns. Prepare clear, accurate, and timely written responses that communicate findings, resolutions, and next steps to participants and their representatives. Track, document, and report grievance outcomes to support internal quality improvement efforts and compliance audits.

+ Triages case inquiries, appeals, and prepares case files/packets for appeal hearings. Attend State Fair Hearings and provide testimony on rationale used for internal decisions to review boards, legal representatives, providers and regulatory agencies. The Specialist must be able to explain decision rationale and connect it to MDHHS contract requirements.

+ Collaborates with the Supervisor and/or applicable SME, to ensure appropriate understanding of contract, regulatory, and accreditation standards. Communicate with other individuals as necessary, both internal and external to the agency prior to the completion of decision notice correspondence or investigative findings.

+ Utilize established clinical criteria, MPM, MI Choice contract, other resources and clinical evidence to develop sound and well-supported appeal and investigation correspondence. Maintain current knowledge of internal policies and processes, accreditation standards, existing and new laws. Ensure forms and documents are up to date with current standards .

+ Other duties as assigned (to view the entire job description, please select the "download" button).

Qualifications

QUALIFICATIONS:

+ RN Candidates: Minimum Assoc. or Nursing Degree with current State of MI nursing license required.

+ Candidates with Experience: Must have 2-4+ years of experience in an administrative clinical setting, including 1-2 years Medicaid managed care appeals process & Health/Human Services.

+ Proven ability to foster and maintain open, collaborative and constructive relationships with co-workers, AgeWays leadership, and individuals external to the agency to achieve departmental and operational results.

+ Strong analytical, critical thinking, and problem-solving skills.

+ Possesses experience in Medicaid managed care appeals process, HIPAA privacy rules, and electronic medical records.

+ Previous knowledge of and the ability to maintain program compliance and regulations.

+ Excellent interpersonal, communication, organizational, training, and investigative skills. The ability to conduct clinical case/documentation reviews, present findings and appeals recommendations. Effective time management skills, including the ability to meet deadlines.

+ MS Office Intermediate to Advanced.

OUR INDUSTRY-LEADING BENEFITS CONSISTS OF:

Choice of 3 excellent next to zero cost Medical Plans including Dental and Vision.

401K - Agency contributes 50% match up to first 6% contribution.

Fitness and Wellness programs.

Excellent PTO package- Minimum 4 weeks accrual for the first year.

Get 10 paid holidays and 3 floating.

Mileage reimbursed for business travel.

Work schedules consist of hybrid, community-based, or office-based.

Our recruiting team would love to hear from you today! Please complete our on-line application and submit your resume for immediate consideration. The Area Agency on Aging 1-B is an Equal Opportunity and Affirmative Action Employer.