Job Summary

Responsible for the analysis, research and completion of complex member grievance investigations. Effectively administer all steps of the member grievance. Thoroughly investigate member grievances, leveraging critical thinking skills, gathering relevant information from enterprise-wide systems, and collaboration to resolve issues whenever possible. Ensure compliance with all mandated, legislative, regulatory and accreditation requirements. Assist members and staff throughout the process by providing complete information and follow up on a timely basis. Ensure committee, State and Federal decisions are properly implemented. Assist the Supervisor and/or Manager in coordinating activities and in the development/collection of materials required to meet and demonstrate compliance to all state, federal and accrediting organization requirements. 
 
The Grievance Analyst makes decisions on moderately complex issues and work is performed without direction. Exercises latitude in determining objectives and approaches to assignments.

Essential FunctionsResponsible for complex and thorough investigation of grievances: formulate action plan to ensure all activities are completed by the regulatory time line, gather all relevant information for the grievance captured (internal documentation from enterprise-wide systems including: claims payments, billing and enrollment, care management, medical, pharmacy and behavioral health authorizations, customer service interactions, prescription claims, medical policies, and plan documents).Track all activity including communication for each grievance by entering complete documentation of issues and related follow-up, ensuring all customers receive required correspondence according to time line requirements and to ensure all regulatory reporting requirements are met.Conducts root cause analysis to determine corrective actions related to the grievance process by researching systemic issues to determine course corrections.Perform quality assurance reviews for case files, decision forms, documentation and logs to ensure they are complete, organized and secure and ensure all procedures are followed and time line requirements are met, including implementation of relevant Committees as needed. Support with providing education and communicates training needs to Customer Service Leadership, when appropriate.Collaborate with cross-functional departments to implement improvements to member experience, medical policies, legal documents, member materials, departmental processes and workflow.Support in conducting root cause analysis to determine corrective actions related to the grievance process by researching systemic issues to determine course correctionsApply strong analytical skills and business knowledge to investigation, analysis and recommendation of solution Communicates, collaborates and acts as a consultant to internal and external customers in order to resolve complex issues.

Qualifications

Required

Associate's Degree or equivalent2 years of relevant experience Member of Provider Customer Service, claims, Legal and/or enrollment/eligibility

Preferred

Bachelor's Degree or equivalentWorking knowledge of Priority Health systems for claims payment, care management, authorizations, customer service interactions, pharmacy Rx profiles, medical policies and plan documents for Medicare product lines2 years of relevant experience Extensive knowledge of managed care products and regulatory and accreditation requirements, maintain knowledge of policies and procedures, including medical policies which may impact the appeal and review processPrevious experience with grievance and appeals processes.

About Corewell Health

As a team member at Corewell Health, you will play an essential role in delivering personalized health care to our patients, members and our communities. We are committed to cultivating and investing in YOU. Our top-notch teams are comprised of collaborators, leaders and innovators that continue to build on one shared mission statement - to improve health, instill humanity and inspire hope. Join a nationally recognized health system with an ambitious vision of continued advancement and excellence.

How Corewell Health cares for you

Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here.

On-demand pay program powered by Payactiv

Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!

Optional identity theft protection, home and auto insurance, pet insurance

Traditional and Roth retirement options with service contribution and match savings

Eligibility for benefits is determined by employment type and status

Primary Location

SITE - Priority Health - 1231 E Beltline - Grand Rapids

Department Name

PH - Grievance And Appeals Medicare

Employment Type

Full time

Shift

Day (United States of America)

Weekly Scheduled Hours

40

Hours of Work

8:00 a.m. - 5:00 p.m.

Days Worked

Monday - Friday

Weekend Frequency

On-call weekends

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Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief.

Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.

An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team.

You may request assistance in completing the application process by calling 616.486.7447.