Fallon Health Member Appeals & Grievances - Growing Health Care Org! in Worcester, Massachusetts
About Fallon Health :
Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation’s top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit.
The Fallon Health Appeals and Grievance process is an essential function to Fallon Health’s compliance with CMS regulations, NCQA standards, other applicable regulatory requirements and member expectations. The Fallon Health Member Appeals & Grievances Coordinator serves to administrate the Fallon Health Appeals and Grievance process as outlined in the Plan Member Handbook/Evidence of Coverage, departmental policies and procedures, and regulatory standards. The Member Appeals & Grievances Coordinator serves as a liaison between Fallon Health members and Fallon Health with their complaints regarding denied claims, referrals, membership and benefit issues and any grievances regarding quality of care or service. The Member Appeals & Grievances Coordinator is responsible for presentation of the member appeal to the Plan Medical Director, Center for Medicare/Medicaid Services, contracted reviewer, and the Plan contracted external review agency in accordance with applicable laws, organization policies, and regulatory requirements. Thorough research, documentation, and corrective action planning must be established for each respective case and effectuation completed in accordance with existing regulations, policies and standards.
Administrate FCHP Standard and Expedited Appeals Processes as outlined in Member Handbook/Evidence of Coverage for all products, and in compliance with applicable NCQA standards and other state or federal regulatory requirements. Strict adherence to department turn-around time standards established in accordance with regulatory standards is required
Act as the primary investigator and contact person for member grievances and appeals, which includes sending the appropriate acknowledgement of the grievance/appeal, educating the member and/or member representative about the grievance/appeal, gathering all pertinent and relevant information from the member regarding the grievance/appeal, notifying the appropriate parties of the resolution and ensuring that all internal processes are completed to resolve the issue.
Conduct non-biased, accurate, timely and comprehensive investigation of all facts related to the grievance/appeal.
Thoroughly document all action taken on behalf of the member to resolve the grievance/appeal
Ensure that all grievances/appeals are processed in adherence to state and federal regulations (i.e. CMS, MassHealth, OPP), contractual obligations, NCQA guidelines and Plan policy.
Ability to interpret and operationalize multiple products and regulatory requirements and differences in each.
Ability to multitask and respond quickly and accurately to issues and concerns for members and internal departments.
Research, investigate and document all plans for corrective action.
On-call approximately one holiday (3-day) weekend per year and one 2-day weekend every 5 weeks and as needed. Available by cell phone to accept new expedited appeal requests and, where necessary, to present to the FCHP office to process request within applicable turn-around time standard.
Special projects as assigned by Management.
Conduct case management of legal/risk issues regarding member complaints, weighing interests of all customers, both internal and external
Adhering to FCHP confidentiality policy; document, research and review member complaints, involving quality of care or quality of service with appropriate clinical and/or administrative staff.
Work with Team Leaders, Department Managers, Department Chairs and/or Medical Director to resolve member complaints; formulate improvement measures and response to member; prepare written correspondence to member.
Forward all documentation involving member quality of care or quality of service complaints to FCHP administration and FCHP Quality Management Department.
Adhere to department standards for completion of member complaints.
Research and resolve system-wide issues, deficiencies, problems and formulate quality improvement measures.
Education: College degree (B.S. or B.A.) or equivalent
Experience: 1-3 years previous professional experience in related position (preferably in health care)
Job ID 5617
# Positions 1
Category Customer Service