Meridian

  • Grievance and Appeals Nurse Coordinator

    Job Location US-MI-Detroit
    Job ID
    2018-5621
    Category
    Grievance & Appeals
    Business Line
    CMC Corporate
  • Overview

    Who we are:

     

    Meridian Health Plan is a family-owned, family-operated company of passionate leaders, achievers, and innovators dedicated to making a difference in the lives of our members, our providers and in the healthcare industry.

     

    We provide government-based health plans (Medicare, Medicaid, and the Health Insurance Marketplace) in six different states (Michigan, Illinois, Iowa, Indiana, Kentucky, and Ohio).

     

    Our employees work hard, play hard, and give back. Meridian employees enjoy: Happy hours, special events, company sports teams, potlucks, Bagel Fridays, weekly Executive Lunches, and volunteer opportunities.

     

     

    A Day in the Life of a Grievance and Appeal Nurse Coordinator:

     

    This position is responsible for ensuring that appeal and grievances that are clinical in nature, are handled appropriately within established timeframes, guidelines and protocol for clinical decision-making. Successfully maintains National Committee for Quality Assurance (NCQA), URAC or general accreditation status with regard to appeal and grievance decision letters. Responsible for the writing and final editing of all letters sent out for appeals. This position ensures that each employee that is part of the appeal process meets their timeline with a 100% accuracy rate.           

    Responsibilities

    • Responsible for handling all clinical aspects of the appeal processes within the department to promote consistency and accuracy within the processes and compliance with NCQA, URAC or general accreditation, regulatory requirements and HIPAA guidelines

    • Ensures staff meets all relevant regulatory requirements and comprehends and complies with best practices, professional standards, internal policies, and procedures
    • Recognizes opportunities to improve the quality of care/services and activities to continually strive to improve outcomes
    • Responsible for providing clinical expertise or in reviewing, researching, investigating, negotiating and resolving quality of care grievances, grievances that are clinical in nature and medical necessity appeals
    • Responsible for reviewing and editing grievance and appeal decision letters to ensure clinical accuracy
    • Conducts intake/triage and appropriate classification of Clinical Appeals, Grievances, and State Fair Hearing and External Review requests and makes accurate judgment on appeal, grievance, Provider Claim Disputes, medical records or other issues and follows procedures on how to handle each type of request and route to the appropriate area within the department
    • Communicates with appropriate parties, issues, implications and decisions. Analyzes and identifies trends for appeals
    • Coordinates with the appeal committee on all cases where an Appeal or Fair Hearing has been imitated in order to ensure that existing clinical documentation accurately reflects the service needs of the members
    • Responsible for clinical coordination and presentation of information for administrative hearings and state external reviews
    • Reviews and participates in appeals that go to the state fair hearings. Assists with the preparation and ground work for each hearing maintaining a better than 99% reached verdict in favor of the health plan
    • Triage of clinical Provider Complaints/PDR (grievances/appeals) utilizing regulatory and internal guidelines and SLA
    • Daily prioritization of clinical workflow for optimizing impact on department production
    • Responsible for each IRO supporting the health plan’s decisions and ensures that they meet the critical time lines
    • Works with the IT department on MCS development issues as it pertains to grievances and appeals
    • Prepares, with the department assistant, Pre-Service appeal for review by the appeals committee. Materials are prepared when the call to the member is placed
    • Assists the Complaint Specialist and State Director of Operations with the member complaints that involve clinical issues
    • Investigates relevant clinical complaints; researches and provides written summary to support the health plan’s decision
    • Utilize professional knowledge, MHP knowledge and pertinent resources or use the appropriate reporting structure to solve problems and issues as identified
    • Maintain strict confidentiality of employee and organizational information in accordance with MHP, HIPAA and State privacy regulations
    • Perform other duties as assigned

     

    Qualifications

    What you can bring to Meridian:

    • Current licensure to practice as a Registered Nurse or a Licensed Practical Nurse in the designated State, without restriction
    • Three to five years of experience, education and/or certifications in utilization management, case management or other appropriate health care specialty

    What Meridian can offer you:

    • Our healthcare benefits include a variety of PPO plans that are effective on the first day of employment for our new full-time team members.
    • Opportunity to work with the industry’s leading technologies and participate in unique projects, demonstrations, conferences, and exclusive learning opportunities.
    • Meridian offers 401k matching that is above the national average.
    • Full-time Meridian employees are eligible for tuition reimbursement towards Bachelor’s or Master’s degrees.
    • Meridian was named Detroit's #1 Fastest Growing Company by Crain's Magazine, so it is a great time to get involved with Meridian

     

     Meridian is an EEO Employer

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