Provides support to the Plan by providing resolution of complex clinical complaints, grievances and appeal. Reviews documentation and interprets data obtained from clinical records to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and provider issues. Independently coordinates the clinical resolution with internal/external clinician support as required. Documents and summarizes results to all parties involved in the case.

• Represents the Plan by providing complex clinical support as needed for corporate, department and other special projects specific to Complaints, Grievance, and Appeals. Responsible for drafting recommendations concerning items impacting Complaints, Grievance, and Appeals and for communication and solution to issues.
• Identifies, reviews and analyzes complex clinical issues regarding current corporate policies and procedures which are identified internally or through Complaints, Grievances, and Appeals. Reaches out to Management, Government Programs, and/or other external contacts (e.g., group leaders) to discuss questions and issues. Makes recommendations to improve, update and clarify any items that may require additional development/revision
• Follows up on all policy and procedure changes to ensure implementation. Requests/initiates the revision of supporting documentation (e.g., policy manuals, procedure manuals, bulletins, etc.).
• Functions as department liaison to resolve cases/issues that require legal recommendations and direction.
• Provides point of clinical reference for Plan personnel to request and receive information concerning resolution of inquiries in accordance with guidelines - including CMS, NCQA, Provider Contracts, and the established Member Touchpoint Measures (MTM) at the level set by the National Blue Cross and Blue Shield Association to achieve quality performance goals set forth by all entities.
• Takes action or makes recommendations to Management to improve service through interacting with other Plan personnel. Additionally the incumbent may: Conduct peer reviews and document findings as assigned; Provide audit support; Provide desk mentoring for new staff and staff undergoing cross-training; Provide functional training for peers, as required by workload.
• Supports department by providing on-call weekend and holiday coverage on rotating basis.

Skills:

• Ability to interact with other departments, as needed, to advise, educate and/or direct members to appropriate services
• Demonstrated analytical, research and organizational skills in order to identify and analyze trends, discrepancies, and issues in reference to Plan policies, procedures and contracts
• Demonstrated verbal communication skills, with the ability to express opinions and research findings to management personnel. Demonstrated written communication skills, with the ability to produce clear, thorough, and detailed letters, memos and reports regarding complex subject matter
• Demonstrated project management skills, ability to manage multiple assignments, adjust to changing priorities and perform assignments independently
• Familiar with the utilization of various software such as Microsoft Office Suite

Knowledge:

• Knowledge of URAC and NCQA standards for case management organizations and CMSA Standards of Practice for Complaints, Appeals, and Grievances
• Knowledge of managed care principles and emerging health treatment modalities. Ability to operate a personal computer (PC), including proficiency in Word, Access, Excel and Outlook and Clinical Databases utilizing a talk and type method of documentation

Experience:

• A minimum of 5 years clinical experience to include working knowledge of Medicare C and D.

Education and Certifications:

• Bachelor’s degree is required
• RN Certification is required

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues and be encouraged to volunteer in your community.  We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.