Grievance and Appeals Administrator (Manager)
The Grievance and Appeal Administrator (Manager) is responsible for oversight of the full grievances and appeals process for Health Choice Integrated Care (HCIC) Members. This position further ensures compliance with member rights including notices and decisions as required by law and Arizona Health Care Cost Containment System (AHCCCS) policy. The Grievance and Appeals Administrator is prohibited from acting as or under the supervision of HCIC's in-house legal counsel, retained legal counsel corporate counsel or risk management attorney.
- Manages, oversees, implements and administers all aspects of the grievance and appeals system processes consistent with AHCCCS requirements for members, subcontractors and providers.
- Investigates and processes grievances and appeals for members and providers in accordance with state and AHCCCS guideline in a timely, accurate manner consistent with law and contract requirements and terms.
- prepares legal memoranda regarding decisions and represents HCIC at state fair hearings regarding decisions, Title XIX, and claims appeals.
- Reviews, analyzes, complies data, recommends and reports on individual and agency providers to the Chief Executive Officer, the Chief Medical Officer, the Integrated Leadership Quality Council, the Integrated Quality Management Committee, the Integrated Provider Advisory Committee, Quality management Department and AHCCCS as appropriate and required.
- Review and revises policies and procedures in collaboration with HCIC Executive Leadership and AHCCCS to ensure accurate and consistent application of AHCCCS requirements.
- Provides technical assistance and/or training to providers and HCIC staff regarding grievances, appeals, and Notice of Action processes in accordance with AHCCCS requirements.
- travel may be required
Health Choice exists to improve the health and well-being of the individuals we serve through our health plans, integrated delivery systems and managed care solutions. We strive to recruit and retain only the finest health care professionals with the highest levels of integrity, compassion and competency. If you are driven by your own personal commitment to these values and desire to work in a team-focused collaborative and supportive environment - while still being valued for your individual strengths - Health Choice is the place for you.
Equal Opportunity Employer Minorities/Women/veterans/disabled
This position requires the employee to reside in Arizona within the assigned Geographical Service Area in Greater Arizona.
High School Diploma / GED
Juris Doctor degree from an accredited institution required
Council on Licensure, Enforcement and Regulation (CLEAR) Certification
Knowledge and abilities:
Experience in behavioral health investigations and medications/alternative dispute resolution.
Knowledge of Laws, rules, regulations, policies and legal practice related to health and behavioral heath and managed care
knowledge of and maintain compliance with AHCCCS contract requirement
Ability to use electronic word processing, email and electronic database resources to solve complicated problems.
Ability to multi-task projects and issues on fixed timelines.