The Grievance and Appeals RN Specialist resolves grievances, appeals and external reviews for one of the following VNSNY CHOICE 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 in a fast paced environment and effectively manage multiple grievances and appeals simultaneously.
- 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.
Licensure: License and current registration to practice as a registered professional nurse in New York State required. Education: Bachelor's or Master's Degree in Nursing preferred. Experience: Minimum three years progressive professional experience in health care, including a minimum of two years in a grievance and appeals or related area such as medical or utilization management in a Managed Care setting, required. Proficient verbal/written communication skills required. Proficient computer and typing skills and knowledge of Microsoft Office (Word and Excel) required. Ability to wo
The Visiting Nurse Service of New York (VNSNY) is the nation's largest not-for-profit home- and community-based health care organization, serving the five boroughs of New York City, and Nassau, Suffolk, and Westchester Countries. For over 125 years, VNSNY has been committed to improving the health and well-being of people through high-quality, cost effective healthcare in the home and community. We offer a wide range of services, programs, and health plans to meet the diverse needs of our patients, members, and clients from before birth to the end of life. Each day, more than 13,000 VNSNY employees - including nurses, rehabilitation therapists, social workers, other allied professionals, and paraprofessionals - deliver compassionate care, unparalleled medical expertise, and 24/7 solutions and resources to more than 44,000 patients and members, helping them to live the best lives possible in their homes and communities.