The Appeals and Grievances Clinical Specialist is responsible for reviewing and resolving grievances and appeals for HSCSN
under the direction and general supervision of the Manager of Appeals and Grievances. This position is accountable for
ensuring regulatory compliance, timeliness requirements and accuracy standards are met. Supports day-to-day functions and
operations of the Appeals and Grievances Department. Creates and maintains accurate records documenting the actions and
rationale for each grievance and appeal. Develops correspondence communicating the outcome of grievances and appeals.
Assists with collecting and reporting data for the risk management program. May assist in the case preparation at Fair
Hearings.
Minimum Education
Associate's degree in nursing or related field - Required
Bachelor’s degree in nursing or related healthcare field - Preferred
Minimum Work Experience
3 years Appeals and Grievances experience - required
5 years Managed Care experience - required
3 years Acute, Med-Surg, or Ambulatory care experience in a clinical role - required
Required Licenses
Registered Nurse - eligible for DC license upon hire OR Licensed Clinical Social Worker for DC - required
Required Certifications
Certified or willing to become certified WITHIN ONE YEAR OF HIRE in either CPPS (Patient Safety) or CPHRM (Risk Management) - preferred
Required Skills
• Knowledge of health care evaluation methodology, medical terminology, and regulations Strong organization and data management skills, including word processing, spreadsheets, monitoring and evaluation tools
Detail oriented with a strong sense of follow-up and completion.
Experience using time management skills such as prioritizing/organizing and tracking details and meeting deadlines of
multiple projects with varying completion dates.
Clinical experience that has been either recent, lengthy/and/or diverse
Awareness of industry and local/national Risk Management trends and strategies
Fluency in electronic medical record documentation of clinical care
Clinical experience with acute care and ambulatory care operations
Knowledge of applying medical necessity criteria
• Ability to verbally communicate effectively with individuals internal and external to the organization.
Conflict Management skills and self-confidence for resolution of outcomes with dissatisfied patients/customers or those for
which an outcome was sub-optimal
Expert verbal and written communication and presentation skills.
Strong analytical, organizational, and interpersonal skills.
Advanced proficiency with Outlook, Microsoft Excel, and Word applications
• Act as a resource to the organization regarding compliance with local, state, and federal laws, regulations, standards, and
requirements of regulatory and accreditation agencies. Ensures compliance with contractual requirements (CASSIP).
Conduct investigations through clinician interview, medical record review and environment of care assessment.
Provides guidance on risks that may impact the appeals and grievance operations.
Assist the Appeals and Grievances Manager in conducting root cause analysis in preparation for appeals and grievances
committee meetings. Participates in committees representing Department.
Facilitate disclosure conversations with clinicians and patient/family members related to appeals and grievances
Maintains knowledge of Appeals and Grievances requirements in accordance with federal, state, and contractual
requirements.
Serves as the organization’s subject matter expert on the Chart Retrieval & Clinical Review platform, including
interactions with and impacts on adjacent services. Maintains appropriate documentation to meet regulatory reviews.
Support client learning and improvement by partnering with clients, being consultative, sharing best practices, maintaining
trust, and providing actionable data.
Build relationships with other departments and internal and external customers to enhance communication regarding
appeals and grievances.
• Investigates and coordinates the resolution of routine and complex grievances and appeals related to medical necessity
and clinical quality of care 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.
Identifies potential conflicts when reviewing and resolving appeals and grievances and notifies Appeals and Grievances
manager of such conflicts.
• Manages appeals and grievance process in accordance with the organization's policies and procedures
• May perform other duties in addition to those outlined in this job description