Grievances & Appeals Senior Specialist

GENERAL DESCRIPTION: Analyzes, investigates, resolves, and answers grievances received through the Center for Medicaid and Medicare Services (CMS) and Complaint Tracking Module (CTM), pre-service appeals, Office of Insurance Commissioner (OCS), and Administrative Organization Determinations (AOD). Ensure timely resolution of cases following contractual obligations and regulatory requirements applicable across all lines of business (LOB) in the company. ESSENTIAL FUNCTIONS: Records, manages, and resolves cases submitted through the CTM.

Complies with verbal contact with the insured and/or authorized representative, or provider during the CTM case investigation process to document and categorize the issue presented and review the documentation provided by operational areas to ensure proper resolution of cases. Document in English the chronology of investigation and resolution on the CMS database, applying the contractual language of benefits and covered services according to the evidence of coverage, or others. Evaluate in the investigation whether a root cause can be identified for the issue.

If a root cause is determined, collaborate with the management of the affected operational areas to develop and implement corrective action plans aimed at minimizing the recurrence of CTMs or grievances. Actively participate in the CTM workgroup, engaging with leaders from other departments or units to review RCA and coordinate on sustainable action plans to prevent future occurrences. Complies with the validation and registration on electronic platforms, as applicable for the pre-service appeals processes, such as Clinical, Dental, SSBCI, and Part B medication.

If a reconsideration or member request for a pre-service appeal is denied by the Classicare LOB, it is responsible for submitting the cases to the CMS contracted Independent Review Entities (IRE - Maximus). If the reconsideration or member request is denied by the MCS Life LOB, and the member requests a second-level appeal, it must follow the compliance guidelines of the OCS regulations and submit the cases to the Independent Review Organizations (IRO). Case files must be documented in English during the appeals process, considering the required records and timeliness.

Reviews and validates Classicare members’ requests to determine eligibility for processing on the electronic platform, ensuring compliance with investigation protocols, evaluation standards, and timeliness requirements, following the company’s Evidence of Coverage. Document notes or chronology of CTM’s, AOD’s, and pre-service appeals investigations in the electronic platform to evidence proper management. This includes attachment of documentation related to the case and evidence of written notices to members or providers, based on the regulatory requirements. Monitors CTM’s and appeals processes to avoid impact on the Stars metrics related to CTM, Appeals Timeliness, and Appeals Review (Upheld).

Supports in the unit rotation process by responding to inquiries related to pre-service appeals and AODs. Ensures appropriate referrals to other departments for cases that do not qualify as appeals or AODs, assigns cases to relevant specialists, and accurately updates internal logs and systems. Responsible for overseeing the on-call program and monitoring processes related to the unit. This includes supervision of corporate cell phone usage assigned to the unit and ensuring timely access to staff by company personnel and regulatory agencies during and outside regular business hours, including evenings, weekends, and holidays.

This is a regulated function that requires continuous availability and compliance with applicable regulatory requirements, to mitigate operational and compliance risks. Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices. May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document. MINIMUM QUALIFICATIONS: Education and Experience: Bachelor’s Degree in Business Administration, Finance, Social Services, or Criminal Justice.

At least four (4) years of experience in the areas of Research, Auditing, or Client/Provider Service, preferred in the Healthcare Insurance Industry. “Proven experience may be replaced by previously established requirements. ”Certifications / Licenses: N/AOther: Knowledge of the following systems is preferred: HPMS, PMHS, Beacon Healthcare System, and TruCare. Languages: Spanish – Advanced (comprehensive, writing and verbal)English – Advanced (comprehensive, writing and verbal)“Somos un patrono con igualdad de oportunidad en el empleo y tomamos Acción Afirmativa para reclutar a Mujeres, Minorías, Veteranos Protegidos y Personas con Impedimento”