For more information and to apply, please visit https://recruiting.adp.com/srccar/public/RTI.home?c=2165301&d=External&r=5000898842306&_fromPublish=true#/
Analyze, research, develop, and update policies, procedures, process and quality improvement efforts and related documentation necessary for regulatory and contractual requirements. Analyze, research, develop, and update reports on member and provider appeals, grievances, and aspects of health plan coverage consistent with contract, regulatory and/or accreditation requirements.
- Bachelor's degree and three years of related work experience, or an equivalent combination of education and related work experience.
- Development/use of business reporting or statistical summary data systems or similar health-related business information systems.
- Demonstrated ability to follow through completion of assignments.
- Basic working knowledge of Microsoft Office applications, including but not limited to Word, Excel, PowerPoint, and Outlook.
- Effective verbal and written communication skills.
- Organizational skills for tracking multiple projects and priorities.
Duties and Responsibilities:
- Analyzes, researches, develops, and updates all appeals and grievance reports including, but not limited to, department inventory, trending, regulatory requirements, audits, employer group and internal department scheduled and ad hoc requests.
- Understands inventory tracking system application to develop new, more efficient use of the system to meet reporting requirements, and to recommend and implement improvements and provide remedial user training to ensure compliance.
- Identifies required changes to policies and procedures based on case resolution outcomes, statutory or regulatory changes, and accreditation requirements.
- Proposes changes to management based on identification and analysis.
- Analyzes and identifies issues that require inter-department efforts to resolve, then coordinates discussions and meetings to implement solutions.
- Presents recommendations to internal committees and department management and assists with the implementation of needed changes and improvements.
- Assists supervisor/manager in responding to internal investigations, reviews, and audits; regulatory inquiries; and accreditation-related audits.
- Evaluates/monitors work performance of staff through real-time dashboards and look-back analytics and reports progress, barriers, and solutions to Senior Manager.
- Collaborates with other departments to improve processes and workflows across departments.
- Facilitates cross-departmental discussions and actions to promote effectiveness and efficiencies.
- Takes a proactive role in digesting and communicating any new regulation, standard, business change, etc. affecting the member advocacy and/or grievance and appeals process.
- Assists in the coordination of changes among departments.
- Assists in determining internal and external impacts.
- Finalizes presentations of internal and external appeals reviews, including performing quality assurance of case documents.
- Conducts presentation for internal committees and groups relating to processes and reports.
- Other Duties/Functions
- Performs all other miscellaneous responsibilities and duties as assigned or directed.
Equal Opportunity Employer – Minorities/Women/Protected Veterans/Disabled