Performs triage (intake, classification, setup and assignment) of Grievances and Appeals, and supports Grievance and Appeals (G&A) staff and management in grievance and appeal tracking and workflow for VNSNY CHOICE product lines – Managed Long Term Care (MLTC), Medicare Advantage (MA), Fully Integrated Dual Advantage (FIDA) and Select Health. Assists with maintaining regulatory compliance, timeliness requirements and ensuring accuracy standards are met. Completes day-to-day operational tasks assigned according to defined processes and procedures. Assists with collecting, tracking, and reporting data. Works under moderate supervision.
- Coordinates the triage of new appeals and grievances from all sources (mail, phone, e-fax, routed from other VNSNY CHOICE departments, etc.). Conducts preliminary investigation of case to classify according to CMS and DOH regulatory requirements. Ascertains member eligibility. Enters the case into tracking database, identifies key information, makes a preliminary determination if the case is from a contracted or non-contracted provider and processes accordingly. Assigns cases according to established guidelines.
- Tracks the chain of custody of case records in and out of the department, according to established procedures. Maintains confidentiality of information.
- Maintains knowledge of Grievance and Appeals (G&A) procedures, and CMS and DOH regulatory requirements and timeframes, and prioritizes work accordingly.
- Assists with identifying and researching missing data elements in the various systems that are necessary for the G&A database.
- Assists with preparation of cases sent for the external reviews consistent with established procedures. Assists with entering the case into the Independent Review Entity (IRE) log, tracking receipt, ensuring that the reply is reviewed by the staff and implementing action as appropriate.
- Assists G & A staff with workflows to ensure regulatory compliance. Prepares letters to non-contracted providers requesting the Waiver of Liability form, follows-up and tracks receipt. Prepares letters requesting Appointment of Representative (AOR) forms in grievances and appeals filed on behalf of member representatives. Prepares letters requesting Waiver of Liability (WOL) forms in appeals filed by non-participating providers. Follows up with G & A staff and the provider to request timely access to waiver of liability and AOR forms.
- Monitors various systems for grievances routed to VNSNY CHOICE from internal and external sources such as Customer Service, CMS, DOH and providers.
- Provides customer service support to members and providers requesting grievances and appeals; facilitates communication with them. Answers calls to the G&A line from members and providers, responds to inquiries, researches the status of appeals and follows-up through resolution.
- Recommends improvements in the effectiveness or efficiency of workflows for improved departmental operations and timely customer service.
- Enters data and assists with compiling reports and analysis on the grievance and appeals process.
- Participates in special projects and performs other related duties.
Education: High School Diploma or GED required.
Experience. Minimum of two years of administrative support experience in a health care organization required. Knowledge of DOH and CMS Grievance and Appeals regulatory requirements and procedures for ensuring compliance preferred. Proficient PC skills, including MS Excel, Word, and Access required. Knowledge of Facets computer system preferred.
The Visiting Nurse Service of New York (VNSNY) is one of the nation's largest not-for-profit home- and community-based health care organizations, serving the five boroughs of New York City, and Nassau, Suffolk, and Westchester Counties. For over 125 years, VNSNY has been committed to improving the health and well-being of people through high-quality, cost-effective health care in the home and community. We offer a wide range of services, programs, and health plans to meet the diverse needs of our patients, health plan members, and clients from before birth to the end of life. On any given day, VNSNY employees - including nurses, rehabilitation therapists, social workers, home health aides and other professionals - deliver compassionate care, unparalleled medical expertise, and 24/7 solutions and resources to approximately 40,000 individuals in our care helping them to live the best lives possible in their homes and communities.