Especialista De Querellas Y Apelaciones

Especialista de Querellas y Apelaciones

Regular

Exempt

GENERAL DESCRIPTION:

Analyzes, investigates, resolves, and answers grievances and/or appeals filed by members, insureds, and Providers within the time stipulated contractually for both Lines of Business (LOB) and following the terms stated in the contracts established in MCS and the rights of Patients and Providers.

ESSENTIAL FUNCTIONS:

- Analyzes, investigates, resolves, and answers grievances and/or appeals filed by MCS Classicare or MCS Life policyholders, as assigned and in compliance with CMS regulation, Office of the Commissioner of Insurance (OCI), MCS and Grievances and Appeals Unit Policies & Procedures, others.

- Consults other MCS Departments or Units, as part of the analysis and investigation process, and Delegated Entities and/or suppliers.

- Validates responses from other Departments and/or Units, assessed the possible root cause, identifies areas of opportunity, and requires collaboration and documentation according to the impacted issue.

- Documents the grievances and/or appeals investigations in the Grievances & Appeals management platform to complete the resolution or determination of the case.

- For appeals, in the event a reconsideration or member request is denied, for MCS Classicare LOB, submits cases to CMS contracted Independent Review Entities (IRE - Maximus). Case files must be documented in english under the appeals process, considering required documentation and timeliness. This process impacts directly, two Stars metrics related to timeliness and upheld by IRE.

- For appeals, in the event a reconsideration or member request is denied and request second level appeal, for MCS Life LOB, complies with the Office of the Commissioner of Insurance (OCI) regulation and submits cases to Independent

- Review Organizations (IRO). Case files must be documented in english under the appeals process, considering required documentation and timeliness.

-For Grievances, records, manages, and resolves

- Complies with verbal contact with the insured and/or authorized representative, or provider during the case investigation process to document and categorize the issue presented.

- Reviews documentation provided by operational areas to ensure proper resolution.

- Resolves grievances according to the timeliness established by regulation (24 hours if expedite or 30 calendar days for standard). Also consider Office of Patient Advocate (OPP timeframes.

- Investigation process includes verbal notices, written notices, RCA, if applicable, within others for proper compliance with process.

- Constant monitoring of grievances and appeals timely management and procedure to avoid impact on 3 Stars metrics related to CTM, Appeals Timeliness and Appeals Upheld.

- Complies with the delivery of data required by immediate supervisor to complete reports required by Regulatory Agencies, in the established timeframes and as requested (Example: CMS, ASES, OPP, OCI, other Departments, and/or MCS Units).

- Identifies providers and insureds with recurring grievances and informs immediate supervisor for referral and intervention by the appropriate department(s), e.g., Provider Department, Compliance Department, others.

- Provides training on Grievances and Appeals Policies and Procedures and their impact on the Organization, in the
New Employee Orientation or as requires by the management team.

- Collaborates, as required, in the review of Policies and participates in the definition of grievances and/or appeals
processes with the Manager, Supervisor and Unit Director.

- If required, participates in MCS Operational meeting or Committees that, due to their function, require personnel with experience in managing Grievances and Appeals. For example, Satisfaction Committee, MOC, others.

- Participates in program review and/or implementation projects, where staff with experience in managing Grievances and Appeals is required, if needed, e.g., update of PMHS, Beacon, others.

- 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 Sciences, or Criminal Justice. Minimum of
three (3) years of experience in research, auditing, or client/provider service, preferably within the Health Insurance Industry.

OR

Education and Experience: Associate degree in Business Administration, Finance, Social Sciences, or Criminal Justice or sixty (60)
approved university credits. Minimum of five (5) years of experience in research, auditing, or client/provider service, preferably within the Health Insurance Industry.

Proven experience may be replaced by previously established requirements.

Certifications / Licenses: N/A

Other: Knowledge in Beacon and HPMS preferred.

Languages:
Spanish Intermediate (writing, conversation, and comprehension)
English Intermediate (writing, conversation, and comprehension)

"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"