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GENERAL SUMMARY:

This position is responsible for receiving, analyzing, and assigning Appeals, Grievances and Complaints (A&G) to the A&G Analysts. Responsible for all activities related to maintaining and providing pertinent information for the purpose of regulatory reporting ensuring integrity and accuracy. Assisting the A&G staff with administrative duties, statistical data on the activity of Appeals, Reconsideration, Redeterminations and Grievances, which will identify trends and opportunities to proactively address member concerns and improve the customer experience.

PRINCIPLE DUTIES AND RESPONSIBILITIES:

+ Ensures daily case receipt via mail, fax, email, Customer Message Center and HAP’s documentation application Pega (Customer Services Specialists), and vendor sites. Responsible for investigation, assignment and tracking for Appeals, Reconsiderations, Redeterminations, and Grievances and entry into care management system. Ensures adherence to CMS, NCQA, and DOL regulatory and compliance guidelines.

+ Assists Appeal and Grievance Analyst in providing case data to support all internal and external reporting. Maintains the Access database as the source for departmental information to support Data Validation, NCQA, Medicare 5 Star, MARS and other initiatives.

+ Responsible for providing all case documentation for External Review requests by DIFS, OPM, MAXIMUS, etc.

+ Works with leadership to create and update Correspondences for Medicare Advantage and Commercial members and providers while ensuring compliance with regulatory entities.

+ Works with Client Services Training department to create and maintain updated documents and desk level procedures to ensure new and current staff have resources available for continuing education.

+ Provides administrative support to the Appeal and Grievance Manager and the Appeal and Grievance Analyst. Maintains professionalism and confidentiality and orders departmental supplies. Organizes and oversees the annual case purge performed by the Clerical team.

+ Ensures meetings are scheduled as required and proper materials are prepared, distributed and presented as all meetings including but not limited to departmental, Grievance Pre Hearing and Grievance Committee Hearings.

+ Performs record and document searches, collection and submission for the Legal Department.

+ Creates statistical weekly, monthly and annual reports for Appeals and Grievances activity providing rationale when the activities are skewed; compile annual reporting data using charts and MS Power Point for distribution to internal leadership.

+ Establishes and maintain strong relationships and contacts across departments in addition to external contacts to ensure open communication, team effort and positive work relations. Continues to self-educate on changes in policies and procedures that occur in other departments that could have an impact on the Appeal and Grievance department operations and the servicing of member/customers.

+ Performs other related duties as assigned.

EDUCATION/EXPERIENCE REQUIRED:

+ Associates Degree in Health Care, Business or related field required or 48 credit hours towards degree or an additional four (4) years of relevant and related experience may be considered in lieu of degree.

+ Minimum of two (2) years of customer service experience in an office setting/call center.

+ Demonstrated proficient use and knowledge of various software programs, such as Windows, Microsoft Word, Microsoft Excel, and Access.

+ Minimum of two (2) years of business office experience in health care preferred.

+ Minimum of 2 years’ experience reviewing and processing the intake of appeals, grievances, and claims inquiries.

+ Mail screening required for all lines of business with emphasis on contracted and noncontracted provider appeals that include knowledge of medical appeals, claims investigation and denial reasons within the claims payment system.

Additional Information

+ Organization: HAP (Health Alliance Plan)

+ Department: Appeals and Grievances

+ Henry Ford Health Location: HAP (Health Alliance Plan)

+ Shift: Day Job

+ Union Code: Office/Non-Exempt, HAP

Additional Details

This posting represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and functions. It should be understood, therefore, that incumbents may be asked to perform job-related duties beyond those explicitly described above.

Overview

Henry Ford Health partners with millions of people on their health journey, across Michigan and around the world. We offer a full continuum of services – from primary and preventative care to complex and specialty care, health insurance, a full suite of home health offerings, virtual care, pharmacy, eye care and other health care retail. With former Ascension southeast Michigan and Flint region locations now part of our team, Henry Ford’s care is available in 13 hospitals and hundreds of ambulatory care locations. Based in Detroit, Henry Ford is one of the nation’s most respected academic medical centers and is leading the Future of Health: Detroit, a $3 billion investment anchored by a reimagined Henry Ford academic healthcare campus. Learn more at henryford.com/careers .

Benefits

The health and overall well-being of our team members is our priority. That’s why we offer support in the various components of our team’s well-being: physical, emotional, social, financial and spiritual. Our Total Rewards program includes competitive health plan options, with three consumer-driven health plans (CDHPs), a PPO plan and an HMO plan. Our team members enjoy a number of additional benefits, ranging from dental and eye care coverage to tuition assistance, family forming benefits, discounts to dozens of businesses and more. Employees classified as contingent status are not eligible for benefits.

Equal Employment Opportunity/Affirmative Action Employer

Equal Employment Opportunity / Affirmative Action Employer Henry Ford Health is

committed to the hiring, advancement and fair treatment of all individuals without regard to

race, color, creed, religion, age, sex, national origin, disability, veteran status, size, height,

weight, marital status, family status, gender identity, sexual orientation, and genetic information,

or any other protected status in accordance with applicable federal and state laws.