Grievance & Appeal Specialist

Grievance & Appeal Specialist

Grievance & Appeal Specialist
 

Who are we?

Versant Health is one of the nation’s leading administrators of managed vision care, serving millions of our clients’ members nationwide. We are driven by our mission to help members enjoy the wonders of sight through healthy eyes and vision.

As a Versant Health associate, you can enjoy a comprehensive Total Rewards package, which includes health and dental insurance, tuition reimbursement, 401(k) with company match, pet insurance, no-cost-to-you vision insurance for you and your qualified dependents. We are also invested in your success. There are many opportunities for advancement and development throughout all stages of your career with us.

See how you can make a difference with the support of strong leadership and a team environment.

See Everything, Be Anything™
 

What are we looking for?

The Grievance & Appeals Analyst conducts and documents thorough investigations of all grievance, complaints, and appeal case types, communicating resolution to members and clients in accordance with all state, regulatory, and National Committee Quality Assurance (NCQA) requirements. Requires broad knowledge of plan products, processes, and enrollment rules. Responsible for all aspects of nonclinical appeals, up to and including decision making, considering potential impacts to regulatory compliance. CTM complaints, investigating and response to executive. legislative, and state inquiries are also performed by the Grievance & Appeal Analyst.

Where you will have an impact

• Complete and document thorough investigation of all grievance/complaint and appeals
• Perform research and evaluate output requirements and formats.
• Request and review all related and relevant documentation and assemble case files.
• Ensure accurate documentation of cases in the appeals management system, maintaining compliance with CMS reporting and data validation requirements.
• Effective and compliant effectuation of appeals.
• Communicate business operational requirements to internal groups responsible for compliance reporting.
• Assist with small to intermediate cross-functional projects and change initiatives involved in the design and delivery of process solutions, implementing strategies and control measures, influencing organizational change related to business processes.
• Participate in process improvement meetings and/or discussions, recommending process efficiencies and/or strategies for improvement.
• Ensure quality assurance of appeal/grievance work, assist in development of desktop procedures and/or training materials.
• Review and determine outcome of appeal/grievance, either independently or in conjunction with clinical appeal staff.
• Compose and complete oral and written responses to all parties.
• Communicate effectively with colleagues, successfully articulating issues, problems, and solutions.
• Assist in functional case walk-throughs.
• Other duties as assigned.

What’s necessary to do the job?

• Required, High School Diploma/GED
• Required, 2 + years appeals and grievance experience or related field.

HIPAA & Security Requirements

All Associates must comply with the Health Insurance Portability Accountability Act of 1996 (HIPAA) as it pertains to disclosures of protected health information (PHI) as described in the Notice of Privacy Practices and HIPAA Privacy Policies and Procedures. As a component of job roles and responsibilities, Associates may have access to covered information, cardholder data or other confidential customer information which must be protected at all times. As a result, Associates must explicitly adhere to all data security guidelines established within the Company’s Privacy & Security Training Program.

Versant Health will never request money from candidates who seek employment with us and will never ask for any payment as part of the recruitment process. Versant Health is a proud Equal Employment Opportunity and Affirmative Action employer dedicated to attracting, retaining, and developing a diverse and inclusive workforce. All qualified applicants will receive consideration for employment at Versant Health without regards to race, color, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity or expression, age, disability, national origin, marital or domestic/civil partnership status, genetic information, citizenship status, uniformed service member or veteran status, or any other characteristic protected by law.

The wage for applicants for this position is [$24.04 an hour].

All incentives and benefits are subject to the applicable plan terms.