COVID-19 VACCINATION REQUIRED FOR ALL YCCO EMPLOYEES EXCEPT FOR AN APPROVED ACCOMMODATION FOR MEDICAL OR SINCERELY HELD RELIGIOUS BELIEF. PLEASE SEE ADDITIONAL INFORMATION BELOW.

DEPARTMENT:     Health Plan Operations                           FLSA STATUS:               Non - Exempt

REPORTS TO:       Benefits Administration Supervisor        PHYSICAL STRENGTH:      Light (L)

SUMMARY

This position is responsible for providing 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 project coordination principles and techniques, effect change, assist with documentation of 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.

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ESSENTIAL DUTIES

1. Works internally and with subcontractors to ensure grievance system expectations, documentation, performance, and reporting are clearly understood and provide technical assistance as needed.
2. Ensures appropriate administration of all health plan grievance system functions including preparation, submission and follow up documentation and tracking. 
3. Prepares and monitors grievance system reporting and analysis activities.

JOB DUTIES

Program Support & Coordination

• Applies organizational policies and procedures to coordinate the processing of complaints and grievances to include tracking, documentation, collection, and file maintenance with strict compliance to State and Federal regulatory and contractual requirements.
• Works with partners in collecting information used to resolve complaints and appeals and responds to internal staff or outside providers/vendors as needed.
• Ensures the review and dissemination of all relevant materials are available to appropriate departments and partners for processing.
• Responds to State requests for relevant evidence for reviews/hearings as appropriate.
• Represents Yamhill Community Care (YCCO) during members’ administrative hearings functions including communication (between YCCO, the health plan partner and the Office of Administrative Hearings), movement of required documents and/or representing during an Administrative Hearing.
• Communicates and respond to inquiries, grievances and appeals as required by regulations, policy and department process standards.
• Following policy and regulatory guidance, reviews response and resolution by applicable method to inquiries, grievances and appeals as required by regulations, policy, and department process standards.
• Communicates with internal and external partners, in matters relating to complaints and appeals.
• Tracks and ensures documentation of final adjudication related to internal and third-party clinical reviews of appeals.

Quality Assurance & Reporting

• Oversees and coordinates all Appeal and Grievance activities, ensuring response deadlines are met in accordance with applicable best practice, state and federal guidelines.
• Accurately interprets benefit language from Member and Provider contract language as well as State and Federal Regulation materials.
• Ensures processes are in place for the collection, tracking and timely reporting of grievances and appeals.
• Prepares and presents grievance system reporting and data synthesis.
• Prepares grievance system materials, reports, and presentations to committees and Leadership as requested.
• Participates in the preparation and submission of regulatory and contract required deliverables.
• Works closely with other YCCO departments, including Health Plan Operations and Quality Assurance and Compliance, to assist with audits, including the External Quality Review (EQR), as needed.

Quality Improvement & Technical Assistance

• Serves in a quality improvement role with internal staff, plan partners, and provider network to develop, pilot, and evaluate models to improve member access to services and system experience.
• Provides assistance to YCCO staff, plan partners, providers, and community partners with grievance system navigation and technical support.
• Acts as a subject matter expert to provide technical information and resources to further the understanding of the grievance system scope, timelines, member and provider communication, and oversight reporting responsibilities.
• Makes formal and informal presentations and reports providing updates on grievance system.
• Collaborates with plan members, the healthcare team, plan partners, providers, and to identify member needs and barriers and work to resolve identified issues.
• Contributes to the ongoing review and analysis of the grievance and appeals system and identifies opportunities for improvement.
• Proactively identifies barriers and challenges to the appeals and grievance system.
• Responsible for participating in improvement plans and projects related to assigned functional areas.

ESSENTIAL DEPARTMENT & ORGANIZATIONAL FUNCTIONS

• Proposes and implements process improvements.
• Meets deadlines for completion of workload.
• Maintains agreed upon work schedule.
• Demonstrates cooperation and teamwork.
• Provides cross-training on specific job responsibilities.
• Meets identified business goals that contribute to departmental goals.
• Reports member complaints to the appropriate authority for investigation and follow-up, per protocol.
• Maintains strict confidentiality, observing all HIPAA rules.
• Maintains professional boundaries and effective working relationships with YCCO and staff, members, providers and partners.
• Participates in work-related continuing education when offered or directed.
• Follows departmental and organizational policies and procedures.
• Performs other duties and projects as assigned.
• Respectfully takes direction from Supervisor.

KNOWLEDGE, SKILLS, & ABILITIES

• Ability to write and edit content for written reports and presentations.
• Ability to analyze, collect, prepare, and distribute appropriate materials for meetings as assigned.
• Knowledge of how to locate, assemble, edit, and summarize materials, information and data as requested.
• Excellent listening, interpersonal and customer service skills.
• Ability to establish and maintain effective, collaborative relationships with colleagues, providers, community agencies and Oregon Health Authority (OHA) staff.
• Knowledge of Oregon Health Plan (OHP) benefit package and OHA rules and regulations.
• 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.
• Possess a high degree of initiative and motivation along with the ability to effectively collaborate and plan with others.
• Excellent organizational skills and ability to manage multiple tasks and timelines simultaneously, as well as to perform work with attention to detail.
• Excellent computer skills, including Microsoft Windows, Word, Excel, and Outlook.
• Ability to communicate effectively in all forms of communication.
• Ability to work in an environment with diverse individuals and groups.
• Ability to work across the YCCO region and to work remotely, as needed.

SUPERVISORY RESPONSIBILITIES

This position has no supervisory responsibilities. 

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 health administration, public health, or health related field.
• Minimum of three (3) years’ customer service, claims processing, complaints and appeals, or health insurance industry experience.

   OR:

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

Preferred:

• Minimum of one (1) year of technical writing and conflict resolution experience.

CERTIFICATES, LICENSES AND/OR REGISTRATIONS

This position does not require any certificates, licenses, or registrations. 

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.

ADDITIONAL INFORMATION ABOUT COVID-19 VACCINATION REQUIREMENTS

To safeguard the health of our employees and their families; our members and visitors; and the community at large, YCCO requires all employees to be fully vaccinated against COVID-19 or have an approved medical or religious accommodation as a qualification of employment.

Job candidates that receive a contingent offer of employment from YCCO must provide proof of COVID-19 vaccination, along with a completed attestation that the documentation submitted is true and correct to Human Resources Department;

OR

Submit a completed request for accommodation form due to a medical reason or sincerely held religious belief to the Human Resources Department to begin the interactive accommodation process.