• 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.

Additional Performance Requirements:

• Excellent organizational and time management skills, including the ability to handle multiple tasks and projects in order to meet deadlines
• Excellent written and verbal communication skills, including presentation skills
• Strong attention to detail and ability to consistently produce quality work
• Ability to meet deadlines as established by state and federal regulations, NCQA, contractual obligations and Plan policies
• Ability to maintain a professional demeanor and confidentiality at all times
• Ability to work with a variety of people and circumstances; strong ability to collaborate, negotiate, and reach agreement as appropriate
• Ability to cope well with ambiguity and stressful situations
• Excellent problem solving skills and ability to solve problems with creativity, consistency and flexibility
• Ability to follow departmental and organizational guidelines, policies and procedures in processing grievances and appeals
• Proficiency in Microsoft Word, Excel and Outlook. Ability to quickly learn and master new software applications
• Excellent record management skills
• Ability to work with minimal supervision and manage work effectively
• Demonstrated sensitivity to the needs of every individual to be treated with respect and fairness
• Knowledge of medical terminology