Appeals and Grievances – Registered Nurse

COPE Health Solutions is a national tech-enabled services firm powering success for health plans and for providers in risk arrangements. Our comprehensive NCQA certified population health management platform and highly experienced team brings deep expertise, experience, proven tools, and processes to improve financial performance and quality outcomes for all types of payers and providers. CHS de-risks the roadmap to advanced value-based payment and improves quality and financial performance for providers, health plans and self-insured employers. For more information, visit CopeHealthSolutions.com.

Resolves grievances, appeals and external reviews for one Health Plan LOBs. Ensures regulatory compliance, timeliness requirements set by regulatory agencies, and accuracy standards are met. Coordinates efficient functioning of day-to-day operations according to defined processes and procedures. Creates and maintains accurate records documenting the actions and rationale for each grievance or appeal decision. Develops correspondence communicating the outcome of grievances and appeals to enrollees and/or providers. Completes responsibilities within defined deadlines, so as to avoid negatively impacting Operations. Assists with collecting and reporting data. FLSA Status: Exempt Salary Range : $85,000-$95,000 Reports To: Utilization Management Director Direct Reports : None Location : Remote Travel : Up to 10% Work Type : Regular Schedule : Full Time

Develops and maintains current knowledge of state and federal regulatory requirements related to all aspects of grievances and appeals for Medicare managed care organizations, Medicaid, home health care, managed long term care as well as contractual requirements. Investigates and reviews routine and complex situations and underlying issues, analyzes and solves problems, focusing primarily on issues of medical necessity, quality of care, long term services and supports, etc.. Consults with the member, family, providers and health plan departments as necessary. Identifies and communicates key points from details. Investigates and coordinates the resolution of routine and complex grievances and appeals according to defined processes and procedures ensuring that required timeframes and regulatory requirements are met, accurate and timely follow up is completed and activities are documented as required. Reviews covered and coordinated services in accordance with established plan benefits, application of medical criteria and regulatory requirements to ensure appropriate appeal resolution and execution of the plan’s fiduciary responsibilities. Prepares records for physician review as needed. Conducts review of requests for prior authorization of health services, as required in certain product lines, and prepares written responses consistent with regulatory requirements. Coordinates external case reviews requested by enrollees, including preparing and submitting documentation according to regulatory requirements and tracking external reviews throughout the process. External reviewers include New York State (Fair Hearings), Centers for Medicare and Medicaid Services (CMS), Independent Review Entities and Quality Improvement Organizations. Collaborates with professionals, health plan departments such as Claims and Medical Management, and the third party administrator staff and legal, as necessary, to investigate and facilitate resolution of individual grievances and appeals. Consults with enrollees, providers and the Medical Director, as appropriate. Provides input and recommendations for design and development of policies, processes and procedures for improved department operations and customer service. Reviews information available from Medicaid, Medicare, other payers, and/or professional medical organizations regarding benefit levels and medical necessity criteria. Enters data and assists with compiling reports and analysis on the grievance and appeals process. Provides timely case completion with strict adherence to required regulatory and department timeframes, which may require after hours and weekend scheduled work. Works outside of regularly scheduled hours, as needed for timely case resolution, or as scheduled for coverage purposes by department management.