Grievance & Appeal Specialist - Omaha, NE or Remote
Job no: 497580
Work type: Full Time Regular
Reports to Manager: Michelle Anderson
Recruiter: Mandy Campbell
Categories: Customer Service, Legal/Compliance, Remote Work
|Oversees vendors responsible for Complaint Tracking Module (CTM), grievance and appeals to ensure appropriate resolutions are provided. Provides oversight by regularly monitoring grievance and appeal results. Documents outcomes of monitoring provides analysis of findings and regularly reports results to appropriate committee. Performs research and investigates trends in any related data set which may include members? pharmacy claim profiles or enrolment data to identify problematic cases and determine underlying root causes. Works with vendors to ensure proper resolution such as vendor staff training or updated processes and documentation of corrective steps taken.
WHAT YOU'LL DO:
- Provides approval of CTM responses, monitors and ensures timely CTM resolution, coordinates CTM concerns with the Compliance Department.
- Reviews PBM completed grievances identifying trends and shares this data with other internal stakeholders.
- Monitors grievances through review of randomly selected cases and provides analysis and trending regarding appropriate decision making and timeliness on cases. Documents outcomes provides analysis and regularly reports results to appropriate committee.
- Coordinates all grievances identified through Mutual staff to the PBM, ensuring appropriate research has occurred and the best resolution for the member.
- Monitoring of appeals through review of randomly selected cases and provides analysis and trending regarding appropriate decision making and timeliness on cases. Documents outcomes provides analysis and regularly reports results to appropriate committee.
- Maintains knowledge of Medicare regulations related to grievance and appeals.
- Oversees website and written content referring to grievance and appeal process to ensure accuracy and compliance with regulators.
- Performs quality control review of data validation and audit universes.
- Performs research in members' pharmacy claim profiles as well as in enrolment data to identify problematic cases and determines underlying root causes. Works with vendors to ensure proper resolution and documentation of corrective steps taken.
- Contributes to formulation of corrective actions when required and works with vendors to ensure accurate completion.
- Responsible for validating grievance and appeal data provided by the PBM to be submitted for data validation or audits (internal or initiated by regulators).
- Annually reviews grievance and appeal letters sent by PBM for accuracy.
- Maintains and updates policies and procedures related to grievance and appeal oversight as well as data validation reviews.
- You help promote a culture of diversity and inclusion within the department and the larger organization. You value different ideas and opinions. You listen courageously and remain curious in all that you do.
- You are able to work remotely and have access to high-speed internet.
- BS or BA in Healthcare or related field or equivalent work experience.
- Ability to handle multiple high priority projects with competing deadlines.
- Effective planning, organizational and decision-making skills.
- Strong problem-solving skills and ability to determine root causes.
- Ability to analyze, interpret and utilize significant data to make sound recommendations and/or business decisions. Ability to interpret and apply laws and regulations.
- Strong knowledge and experience in utilizing a personal computer to include various software packages and databases, including Microsoft Word, Excel, and PowerPoint.
- Ability to work independently with minimal supervision.
- Strong written and verbal communication and interpersonal skills.
- Strong organizational skills and the ability to prioritize appropriately.
- Strong customer service skills, grievance and appeal experience preferred.
- National Pharmacy Technician Certification or Certified Pharmacy Technician (CPhT) preferred.
- Experience in health care industry in related field preferred. Project management preferred
PBM experience a plus.
- Medicare Advantage and/or Prescription Drug Plan Experience.
- Medicare, claims processing auditing experience, PBM and/or pharmacy audit experience preferred.
WHAT WE CAN OFFER YOU:
- A diverse workplace where associates feel a sense of belonging
- An organization that feels like a small, close-knit community and has the strength of a Fortune 500 company
- Tuition reimbursement, training and career development
- Competitive salary, incentives, 401(k), flexible work schedules and a healthy amount of time off
MUTUAL OF OMAHA:
Mutual of Omaha serves more than 4.8 million individual product customers and 39,000 employer groups. Our legacy of stability creates an environment where every associate is encouraged to experiment, innovate and grow in their own unique career path.
From day one, you’ll have the tools to be your best self at work. Here you’ll do meaningful work and your talents will have a positive impact on peoples’ lives as we help our customers protect what they care about and achieve their financial goals.
Each associate is a unique contributor to creating a diverse, dynamic, thriving and inclusive workplace. We want you to become engaged … feel a sense of belonging … and contribute to the company’s exceptional future.
Join forces with a company that can AMPLIFY YOUR STRENGTHS AND EMPOWER YOUR CAREER.
For inquiries about the position or application process, contact our HR Helpline at 1-800-365-1405.
If you are a qualified individual with a disability or a disabled veteran, you have the right to request an accommodation if you are unable or limited in your ability to use or access our career center as a result of your disability. To request an accommodation, contact a Human Resources Representative at 1-800-780-0304. We are available Monday through Friday 7 am to 4:30 pm CST we will reply within 24 hours.
Mutual of Omaha and its affiliates are an Equal Opportunity /Affirmative Action Employer. Qualified applicants will receive consideration without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.
To All Recruitment Agencies: We do not accept unsolicited agency resumes and we are not responsible for any fees related to unsolicited resumes.
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Applications close: Central Daylight Time
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