Location : Remote: This position has the possibility of being 100% Remote.

Most of the positions at YCCO are hybrid, meaning they have the flexibility to work both remotely and/or in-person.

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Department: Heath Plan Operations FLSA Status: Exempt

Reports To: Utilization Management Manager Physical Strength: Light (L)

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Summary

Under the general direction of the Utilization Management Manager, and in collaboration with the Health Plan Operations Manager, the Appeals & Grievance RN is responsible for providing clinical program support for all activities related to the Grievance System including complaints, Notice of Adverse Benefit Determination (NOABD), appeals, administrative hearings, and regulatory reporting. Utilizing clinical judgment and project coordination principles and techniques, effect change, document program activities, and monitor progress and quality of outcomes. This position works closely with staff to ensure collaboration, integration, and support across all service areas.

Essential Duties

1. Ensures appropriate clinical review and administration of the health plan grievance system functions including preparation, submission and follow-up documentation, and tracking.
2. Works internally and with subcontractors to ensure grievance system expectations, documentation, performance, and reporting are clearly understood by members, providers, partners, and staff, and provide technical assistance as needed.
3. Prepares and monitors clinical grievance system deliverables, reporting, and analysis activities.

Job Duties

• Serves as primary interface and clinical resource to members, providers, and business partners to ensure grievance system (appeals and complaints) processes are implemented in alignment with State, Federal and other regulatory requirements.
• Collaborates with key departments and staff to prepare for and represent YCCO at administrative hearings via multiple communication modes.
• Processes clinical data and reconsideration prior authorization requests.
• Maintains call tracking system of correspondence and outcomes for provider and member appeals and grievances.
• Oversees monitoring of member submission / resolution to ensure all internal and regulatory timelines are met.
• Documents, investigates, and resolves member and provider issues.
• Acts as a member advocate, clearly communicating the appeal and grievance process and procedures both orally and in writing.
• Develops content for written documentation and correspondence to members outlining final disposition / decision of a member’s appeal or grievance and provide further appeal options as appropriate.
• Manages and collects documents and records (medical, claims, administrative) needed to fully research the appeal or complaint request with both internal and external requests.
• Ensures resolutions are compliant and meets turnaround times requirements dictated by policies and procedures.
• Proactively assess and audits business processes to determine effective and efficient resolution of member and provider problems.
• Makes recommendations on grievance resolution and appeal decisions based on the member’s benefits and individual circumstances presented.
• Maintains confidentiality of all discussions, records, and other data in connection with quality management activities according to professional standards.
• Acts as a resource for clinic staff for problem solving and disseminates educational materials and other resources.
• Participates in collaborative improvement initiatives with other departments and community partners, as needed.
• Prepares narratives, graphs, flowcharts, and reporting as requested.
• Prepares and presents to YCCO leadership and committees for committee grievance system data, audits, and internal / external reports.

Essential Department & Organizational Functions

• Works to cultivate and develop inclusive and equitable services and working relationships with diverse groups of employees, community partners, and community members.
• Participates in the preparation and submission of regulatory and contract required deliverables.
• Works closely with other YCCO departments, including Health Plan Operations and Compliance to assist with audits; including the External Quality Review (EQR), as needed.
• Proposes and implements process improvements.
• Meets deadlines for completion of assigned responsibilities and projects.
• Maintains agreed upon work schedule with punctual, regular, and predictable attendance.
• Demonstrates cooperation and teamwork using a professional and respectful demeanor.
• Provides cross-training on specific job responsibilities.
• Meets identified goals that contribute to departmental goals.
• Works collaboratively in a team and matrixed (cross-department) environment with a spirit of cooperation.
• Respectfully takes direction from Supervisor.
• Other duties as assigned.

**Knowledge, Skills, & Abilities **

• Ability to gather and process complex information and deliver the information, both verbally and written, in a clear, concise, and articulate manner.
• Knowledge of Managed Care / Medicaid requirements.
• Excellent writing and presentation skills.
• Strong conflict resolution skills.
• Strong public speaking skills.
• Extensive investigation, analytical and problem-solving skills.
• Ability to manage a high-volume production environment with time sensitive parameters.
• Able to appropriately handle required functions, prioritize them, and seek assistance when necessary.
• Excellent organizational skills including ability to handle multiple priorities and demands simultaneously in a dynamic work environment while maintaining high attention to detail and accuracy.
• Ability to work independently, use sound judgment, anticipate next steps and be proactive as part of a diverse team within a Matrix or shared resources across departments work model.
• Excellent computer skills, including Microsoft Windows, Word, Excel, and Outlook.
• Ability to communicate both professionally and effectively in all forms of communication.
• Ability to work in an environment with diverse individuals and groups.
• Ability to remain flexible, positive, and adaptable.
• Ability to work across the YCCO region and to work remotely, as needed.

Supervisory Responsibilities

This position has no supervisory responsibility.

Qualifications

Ability to perform essential job duties with or without reasonable accommodation and without posing a direct threat to safety or health of employee or others. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.

Education & Experience

Required:

• Bachelor's degree in Nursing.
• 3-5 years health care or insurance experience.

OR:

• Any combination of education and experience that would qualify candidate for the position.

Preferred:

• Health care benefit and regulatory knowledge.
• Knowledge of Oregon Medicaid grievance system requirements.

Certificates, Licenses and/or Registrations

Required:

• Valid, unrestricted Oregon RN license.

Physical Demands & Work Environment

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential duties of this position. The work environment characteristics described here are representative of those an employee encounters while performing the essential duties of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.

While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to sit, stand, walk, use hands and fingers, handle or feel, and reach with hands and arms. The employee is occasionally required to climb or balance, stoop, kneel, crouch or crawl. The employee may occasionally need to lift and/or move up to 25 pounds.

This position operates in a professional office environment and requires frequent use of standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. Specific vision abilities required by this job include close vision, color vision, distance vision, depth perception, and ability to adjust focus. The noise level in the work environment is usually moderate.

This position may include occasional required or optional travel outside of the workplace, in which the employee’s personal vehicle, local transit, or other means of transportation may be used.