Job Title: Appeals and Grievances Clinical Specialist (240002EF)
Description:
The Appeals and Grievances Clinical Specialist is responsible for reviewing and resolving grievances and appeals for HSCSN under the direction and general supervision of the Manager of Appeals and Grievances. This position is accountable for ensuring regulatory compliance, timeliness requirements, and accuracy standards are met. Supports day-to-day functions and operations of the Appeals and Grievances Department. Creates and maintains accurate records documenting the actions and rationale for each grievance and appeal. Develops correspondence communicating the outcome of grievances and appeals. Assists with collecting and reporting data for the risk management program. May assist in the case preparation at Fair Hearings.
Qualifications:
- Associate's degree in nursing or related field - Required
- Bachelor’s degree in nursing or related healthcare field - Preferred
- 3 years Appeals and Grievances experience - Required
- 5 years Managed Care experience - Required
- 3 years Acute, Med-Surg, or Ambulatory care experience in a clinical role - Required
Required Licenses:
Registered Nurse - eligible for DC license upon hire OR Licensed Clinical Social Worker for DC - Required
Required Certifications:
Certified or willing to become certified WITHIN ONE YEAR OF HIRE in either CPPS (Patient Safety) or CPHRM (Risk Management) - Preferred
Required Skills:
- Knowledge of health care evaluation methodology, medical terminology, and regulations.
- Strong organization and data management skills, including word processing, spreadsheets, monitoring, and evaluation tools.
- Detail oriented with a strong sense of follow-up and completion.
- Experience using time management skills such as prioritizing/organizing and tracking details and meeting deadlines of multiple projects with varying completion dates.
- Clinical experience that has been either recent, lengthy, and/or diverse.
- Awareness of industry and local/national Risk Management trends and strategies.
- Fluency in electronic medical record documentation of clinical care.
- Clinical experience with acute care and ambulatory care operations.
- Knowledge of applying medical necessity criteria.
Additional Skills:
- Ability to verbally communicate effectively with individuals internal and external to the organization.
- Conflict Management skills and self-confidence for resolution of outcomes with dissatisfied patients/customers or those for which an outcome was sub-optimal.
- Expert verbal and written communication and presentation skills.
- Strong analytical, organizational, and interpersonal skills.
- Advanced proficiency with Outlook, Microsoft Excel, and Word applications.
Responsibilities:
- Act as a resource regarding compliance with local, state, and federal laws, regulations, standards, and requirements of regulatory and accreditation agencies.
- Conduct investigations through clinician interviews, medical record reviews, and environment of care assessments.
- Provide guidance on risks that may impact the appeals and grievance operations.
- Assist the Appeals and Grievances Manager in conducting root cause analysis in preparation for appeals and grievances committee meetings.
- Participate in committees representing the Department.
- Facilitate disclosure conversations with clinicians and patient/family members related to appeals and grievances.
- Maintain knowledge of Appeals and Grievances requirements in accordance with federal, state, and contractual requirements.
- Serve as the organization’s subject matter expert on the Chart Retrieval & Clinical Review platform.
- Support client learning and improvement by partnering with clients, sharing best practices, maintaining trust, and providing actionable data.
- Build relationships with other departments and internal and external customers to enhance communication regarding appeals and grievances.
- Investigate and coordinate the resolution of routine and complex grievances and appeals related to medical necessity and clinical quality of care.
- Manage appeals and grievance process in accordance with the organization's policies and procedures.
- May perform other duties in addition to those outlined in this job description.
Primary Location: District of Columbia-Washington
Work Locations: HSCSN - Vermont Ave, 1101 Vermont Ave NW, Washington 20005
Job: Non-Clinical Professional
Organization: HSC W/Special Needs
Position Status: R (Regular) - FT - Full-Time
Shift: Day
Work Schedule: M-F; 8:00AM - 5:00PM
Job Posting: Sep 3, 2024, 2:01:05 PM
Full-Time Salary Range: 81993.6 - 136656
Health Services for Children with Special Needs (HSCSN) is an equal opportunity employer that evaluates qualified applicants without regard to race, color, national origin, religion, sex, age, marital status, disability, veteran status, sexual orientation, gender identity, or other characteristics protected by law.
Please note that it is the policy of Health Services for Children with Special Needs (HSCSN) to ensure a “drug-free” work environment.
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