Appeals and Grievance Regulatory Specialist

Location Address:

Compensation Pay Range:

Summary:

Responsibilities:

Responsible for reporting requirements and regulatory and contractual changes related to the complaint, appeals and grievance process and assists with identifying and responding to issues related to these processes. Under limited supervision, responds to and resolves complex issues related to daily operations, and overall management of the processes to meet regulatory and contractual requirements for oversight bodies of all product lines and to develop and create internal and external reports related to appeals and grievance data for member and providers of all product lines. Facilitates resolution of issues or process improvements by supporting multi-functional teams through data trending, tracking and analyzing. Acts as a resource to the complaints/grievances management staff by providing guidance for; development, training on policies, procedures, processes and reporting criteria requirements

Some key responsibilities include:

• Effectively communicates with all levels of management staff.
• Escalates issues as necessary to include accurate documentation, research and suggested resolutions.
• Communicates trends and recommended resolution time frames.
• Assists with creating, developing and monitoring corrective action plans.
• Develops and presents training to employees as identified by the organization and the manager/director.
• Assists in collecting and coordinating performance reports and metrics.
• Presents performance indicators at meetings and facilitates discussion regarding trends and performance indicators.
• Supports and assists with complaint/grievance management audits to ensure that required processing standards are met and maintained in accordance with all applicable requirements.
• Prepares summary report of findings with recommendations for improvement.
• Responsible for all over sight reporting related to complaint management functions.
• Coordinates the collection of, performance indicators and regulatory reports on a monthly, quarterly and annual basis. Presents performance indicators at all applicable compliance meetings and facilities discussion regarding actions to take as a result of trends in performance indicators.
• Composes responses to RFPs for the health plan and other vendors, as well as commercial, PIC and Medicaid contracts as required and requested, based on data collected by appeals and grievance and complaint data processed in the department
• Supports department manager/director with special projects and/or initiative as needed.

Qualifications:

Bachelor Degree, with 2 years experience in appeals and grievance or customer service

All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits.

Wellness
Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more.

Why work at Presbyterian?
As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans.

About Presbyterian Healthcare Services
Presbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses.

Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.