Grievance and Appeals Quality Analyst

Provide department-specific analysis and quality assurance to the Grievance and Appeals department. This includes analyzing data and processes to identify trends related to operational or quality issues; identifying and implementing process improvements; and supporting departmental training efforts. 

Position overview

• Utilizes G&A data to identify trends and root causes of repeat issues brought to the G&A unit; acts as an advocate for members, summarizing insights and clearly communicating quality monitoring results to the team; clearly communicates findings from trend analysis with G&A management and other internal customer groups.
• Partners with team Lead and supervisor to trend and conduct thorough reviews of G&A case work in alignment with regulations, internal training, and standard operating procedures.
• Designs, develops and produces visualizations of data reports such as tables, graphs, and charts to support reporting and analysis.
• Writes parameters for all G&A reports, including all reports provided to HPSM’s regulatory bodies (i.e. Department of Health Care Services, Department of Managed Health Care, and Centers for Medicare and Medicaid Services) and governing bodies (e.g. Consumer Advisory Committee, San Mateo Health Commission).
• Maintains department desktop procedures, workflows, job aids and training material.  Identifies barriers to work processes and brings to the attention of the Supervisor/Manager.
• Analyzes, creates and tests new tools and processes in order to enhance the department’s assessment and documentation processes.
• Develops and implements work plans for department and individual staff under the direction of the G&A Supervisor and Manager; identifies appropriate resources for tasks and develops appropriate workflows and outcomes.
• Identifies and helps implement staff trainings that addresss team needs, in collaboration with the Lead and Supervisor; this includes:
  • Analyzing and providing written/verbal interpretation of data to identify new team training needs
  • Assisting with the design of new trainings to the team
  • Provide ongoing training and assistance to internal staff as assigned, on how to effectively process grievances and appeals to DHCS and CMS requirements
  • Providing  recommendations to support the Supervisor and Manager in creating tailored training plans for individuals.
• Under the direction of the G&A Supervisor and Manager, leads team preparation for audits and designated responses to regulatory agencies.
• Researches issues related to assigned projects, including regulatory compliance, to identify their impact on the organization.
• Develops and maintains collaborative relationships within the unit and inter-departmentally; collaborates with the HPSM Health Information Management (HIM) team to ensure  all G&A reporting is accurate and conducts quality assurance on the data provided.
• Continuously evaluates processes and makes recommendations to G&A Manager for on-going process improvement, including database design and staff training.
• As needed, provide back-up coverage and support for other members on the team.

Requirements

These are the qualifications typically needed to succeed in this position. However, you don’t need to meet every requirement to apply. 

Education and experience

• Bachelor’s Degree preferred.
• 3+ years of experience in managed care and/or grievance and appeal (Healthcare environment).
• Medicare/Medicaid experience preferred.
• Subject-matter expertise in training and facilitation skills in a group/ classroom setting as well as one-on-one preferred.

Knowledge of:

• Quantitative and qualitative analysis
• Database management, spreadsheets, relational databases, and health care compliant systems
• Local, state and federal health plan guidelines/regulations (including CMS, DMHC, DHCS and NCQA requirements).
• Personal computers and Microsoft Office Suite applications, including Outlook, Word, Excel, Access and PowerPoint.
• Grievance and Appeals processes and concepts in a health insurance managed care setting.
• Health care processes related to maintaining regulatory compliance.

Ability to:

• Prioritize multiple and competing tasks, in a fast-paced and dynamic environment.
• Work under pressure and meet deadlines.
• Work both independently and in a team environment.
• Communicate effectively, both verbally and in writing.
• Analyze data and create reports by utilizing strong analytical skills with high attention to detail.
• Communicate effectively, with a strong emphasis on written and verbal communication.
• Adapt to changes in requirements/priorities for daily and specialized tasks.
• Exercise objectivity in all work functions and approach conflict with curiosity.
• Collaborate and build relationships with a variety of people as part of a cross-functional team.
• Demonstrate a strong customer focus and proactively find ways to exceed customer needs.

Skills:

• Excellent written and oral communication skills, as well as strong interpersonal, critical thinking and analytical skills.
• Excellent organizational, decision-making and multi-tasking skills.
• Keen attention to detail.

Salary and benefits

The starting salary range is $33.32-$42.80 per hour, depending on the candidate’s work experience.

Excellent benefits package includes:

• HPSM-paid premiums for employee’s medical, dental and vision coverage (employee pays 10% of each dependent’s premiums)
• Fully paid life, AD&D and LTD insurance
• Retirement plan (HPSM contributes equivalent of 10% of annual compensation)
• 12 paid holidays a year, 12 paid sick days a year and paid vacation starting at 16 days a year
• Tuition reimbursement plan
• Employee wellness program

It is HPSM's policy to provide equal employment opportunity for all applicants and employees.  HPSM does not unlawfully discriminate based on race, religion, color, national origin, ancestry, physical disability, mental disability, medical condition, marital status, sex, age, sexual orientation, veteran status, registered domestic partner status, genetic information, gender, gender identity, gender expression, or any other characteristic protected by applicable federal, state, or local law.  HPSM also prohibits discrimination based on the perception that an applicant or employee has any of those characteristics or is associated with a person who has or is perceived to have any of those characteristics.