Grievances & Appeals Specialist
MCS Puerto Rico, San Juan, San Juan, United States
General Description
Analyzes, investigates, supports, and answers Grievances, Dental Pre‑Service, and Payment Appeals filed by members, insureds, providers, and/or non‑party providers within the time stipulated contractually for both lines of business (LOB) and following the terms stated in the contracts established and the rights of patients and providers.
Regular – Exempt
Essential Functions
Analyzes, investigates, resolves, and responds to Grievances, Dental Pre‑Service, and Payment Appeals filed by MCS Classicare or MCS Life policyholders, in compliance with CMS regulation, OIC, and internal policies.
Consults and collaborates with other departments or units, dental physician reviewers, delegated entities, and suppliers as part of the analysis, investigation, and support process; validates responses, assesses root causes, identifies opportunities, and ensures proper collaboration and documentation based on impacted issue.
Documents cases and uses the Grievances & Appeals management platform to support analysis and complete resolution; when required, send notifications to Net Claim system to complete dental pre‑service appeals.
Handle case reconsiderations or member requests per applicable regulation and due process to CMS contracted Independent Review Entities (IRE – Maximus). Case files must be documented in English during the appeals process, considering required documentation and timeliness. This impacts two (2) Stars metrics related to Appeals Timeliness and Appeals Review (Upheld).
For appeals, if a reconsideration or member request is denied and a second level appeal is requested, for MCS Life LOB, comply with OIC regulation and submit cases to Independent Review Organizations (IRO). Case files must be documented in English under the appeals process, considering required documentation and timeliness.
For grievances, record, manage, and resolve issues.
Conduct verbal contact with insured or authorized representative, or provider during the case investigation process to document and categorize presented issue.
Review documentation provided by operational areas to ensure proper resolution.
Resolve grievances according to timeliness established by regulation (24 hours if expedited or 30 calendar days for standard). Also consider Office of Patient Advocate (OPP) grievances management timeframes.
Engage in verbal notices, written notices, root cause analysis (RCA), and other processes for compliance.
Constantly monitor grievances and appeals for timely management and procedure to avoid impact on three (3) Stars metrics related to CTM, Appeals Timeliness, and Appeals Review (Upheld).
Deliver data required by G&A Analysts or immediate supervisor to complete reports required by regulatory agencies (CMS, ASES, OPP, OIC, etc.) within established timeframes.
Identify providers and insureds with recurring grievances and inform immediate supervisor for referral and intervention by appropriate departments.
Provide training on Grievances and Appeals Policies and Procedures and their impact on the organization, during new employee orientation or as required by the management team.
Participate in meetings that require expertise in managing grievances and appeals, such as the Satisfaction Committee, Model of Care (MOC), and others.
Participate in program review and/or implementation projects involving grievances and appeals, e.g., update of PMHS, Beacon.
Fully comply with all company policies, procedures, local and federal laws, and regulations applicable to the industry, maintaining appropriate business and employment practices.
May carry out other duties and responsibilities as assigned, according to the qualifications in this document.
Minimum Qualifications Education and Experience
Bachelor's degree in Business Administration, Finance, Social Sciences, or Criminal Justice. Minimum of three (3) years of experience in research, auditing, or client/provider service, preferably within the Health Insurance Industry.
Associate's Degree in Business Administration, Finance, Social Sciences, or Criminal Justice or sixty (60) approved university credits. Minimum of five (5) years of experience in research, auditing, or client/provider service, preferably within the Health Insurance Industry.
Proven experience may be replaced by previously established requirements.
Certifications / Licenses:
N/A
Other:
Knowledge in Beacon and PMHS preferred.
Languages:
Spanish – Intermediate (writing, conversation, comprehension)
English – Intermediate (writing, conversation, comprehension)
Equal Employment Opportunity:
We are an Equal Employment Opportunity Employer and take affirmative action to recruit protected veterans and individuals with disabilities.
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Regular – Exempt
Essential Functions
Analyzes, investigates, resolves, and responds to Grievances, Dental Pre‑Service, and Payment Appeals filed by MCS Classicare or MCS Life policyholders, in compliance with CMS regulation, OIC, and internal policies.
Consults and collaborates with other departments or units, dental physician reviewers, delegated entities, and suppliers as part of the analysis, investigation, and support process; validates responses, assesses root causes, identifies opportunities, and ensures proper collaboration and documentation based on impacted issue.
Documents cases and uses the Grievances & Appeals management platform to support analysis and complete resolution; when required, send notifications to Net Claim system to complete dental pre‑service appeals.
Handle case reconsiderations or member requests per applicable regulation and due process to CMS contracted Independent Review Entities (IRE – Maximus). Case files must be documented in English during the appeals process, considering required documentation and timeliness. This impacts two (2) Stars metrics related to Appeals Timeliness and Appeals Review (Upheld).
For appeals, if a reconsideration or member request is denied and a second level appeal is requested, for MCS Life LOB, comply with OIC regulation and submit cases to Independent Review Organizations (IRO). Case files must be documented in English under the appeals process, considering required documentation and timeliness.
For grievances, record, manage, and resolve issues.
Conduct verbal contact with insured or authorized representative, or provider during the case investigation process to document and categorize presented issue.
Review documentation provided by operational areas to ensure proper resolution.
Resolve grievances according to timeliness established by regulation (24 hours if expedited or 30 calendar days for standard). Also consider Office of Patient Advocate (OPP) grievances management timeframes.
Engage in verbal notices, written notices, root cause analysis (RCA), and other processes for compliance.
Constantly monitor grievances and appeals for timely management and procedure to avoid impact on three (3) Stars metrics related to CTM, Appeals Timeliness, and Appeals Review (Upheld).
Deliver data required by G&A Analysts or immediate supervisor to complete reports required by regulatory agencies (CMS, ASES, OPP, OIC, etc.) within established timeframes.
Identify providers and insureds with recurring grievances and inform immediate supervisor for referral and intervention by appropriate departments.
Provide training on Grievances and Appeals Policies and Procedures and their impact on the organization, during new employee orientation or as required by the management team.
Participate in meetings that require expertise in managing grievances and appeals, such as the Satisfaction Committee, Model of Care (MOC), and others.
Participate in program review and/or implementation projects involving grievances and appeals, e.g., update of PMHS, Beacon.
Fully comply with all company policies, procedures, local and federal laws, and regulations applicable to the industry, maintaining appropriate business and employment practices.
May carry out other duties and responsibilities as assigned, according to the qualifications in this document.
Minimum Qualifications Education and Experience
Bachelor's degree in Business Administration, Finance, Social Sciences, or Criminal Justice. Minimum of three (3) years of experience in research, auditing, or client/provider service, preferably within the Health Insurance Industry.
Associate's Degree in Business Administration, Finance, Social Sciences, or Criminal Justice or sixty (60) approved university credits. Minimum of five (5) years of experience in research, auditing, or client/provider service, preferably within the Health Insurance Industry.
Proven experience may be replaced by previously established requirements.
Certifications / Licenses:
N/A
Other:
Knowledge in Beacon and PMHS preferred.
Languages:
Spanish – Intermediate (writing, conversation, comprehension)
English – Intermediate (writing, conversation, comprehension)
Equal Employment Opportunity:
We are an Equal Employment Opportunity Employer and take affirmative action to recruit protected veterans and individuals with disabilities.
#J-18808-Ljbffr