Grievance and Appeals Specialist, Clinical

VNS Health is one of the nation’s largest nonprofit home and community-based health care organizations. Innovating in health care for more than 130 years, our commitment to health and well-being is what drives us — we help people live, age and heal where they feel most comfortable, in their own homes, connected to their family and community. On any given day, more than 10,000 VNS Health team members deliver compassionate care, unparalleled expertise and 24/7 solutions and resources to the more than 43,000 “neighbors” who look to us for care. Powered and informed by data analytics that are unmatched in the home and community-health industry, VNS Health offers a full range of health care services, solutions and health plans designed to simplify the health care experience and meet the diverse and complex needs of the communities and people we serve in New York and beyond.

Resolves grievances, appeals and external reviews for one of the following VNS Health Plans product lines – Managed Long Term Care (MLTC), Medicare Advantage (MA), or Select Health. Ensures regulatory compliance, timeliness requirements 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. Assists with collecting and reporting data. Works under general supervision.

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. Participates in special projects and performs other duties as assigned.