Appeals & Grievances QA Auditor

Who We Are

Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We’ve had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it’s at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work. 

We enjoy the important work we do every day in service to our members, partners, colleagues and communities. Learn more about who we are at Point32Health.

Job Summary

Under the direction of the A&G Manager, the Appeals & Grievances QA Auditor audits the quality of letters and keyed entries from the Grievance and Appeals systems. Checks cases built by other associates to ensure highest level of quality and timeliness. Provides feedback on findings to colleagues and leadership. Tracks and trends audit findings and identifies areas of opportunity for the A&G (Appeals and Grievances) department. Understands department, segment, organizational strategy and operating objectives, including linkage to other areas. Makes decisions regarding own work methods, occasionally in ambiguous situations and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures. Assists with other projects and workflows within the department (such as external audits with regulatory agencies, training, etc.) as needed.

Job Description

• Review all grievances and appeals prior to case closure including adherence to policies and procedures and regulatory requirements, entries within A&G systems, and letters for members and/or providers.
• Identifies issues with casework, including, but not limited to data entry errors within system, incorrect processes followed, untimely processing, errors on correspondence sent to members and providers, identifying incomplete resolutions and provides feedback to colleagues for corrections.
• Tracks and trends any audit findings and identifies areas of opportunity for the A&G department to reduce the risk of non-compliance with appeals and grievance requirements. These can include, but are not limited to, repeated findings across colleagues or repeating findings with a specific associate. Root cause analysis may be performed to identify areas for quality improvement.
• Hold regular meetings with department leads to discuss issues and trends identified. The A&G auditor will lead these meetings to discuss trends identified through their audits. The A&G leaders will utilize these findings to identify coaching and training opportunities for their teams and reduce the number of errors identified with audit.
• Provides guidance to colleagues regarding established guidelines/procedures and regulatory requirements. This entails one on one or group coaching sessions when a concern is identified through their audit, or a colleague asks for clarification on an existing process. Assists with other projects and workflows as needed.
• Other projects and duties as assigned.

Certification and Licensure

• None

Education

• Required (minimum): Bachelor’s degree or equivalent business experience
• Preferred:

Experience

• Required (minimum):  5 years or more of experience in Appeals and Grievances to include experience utilizing an appeals & grievances software platform. Prior A&G Medicare experience.
• Preferred:

Skill Requirements

• High attention to detail
• Strong written and verbal communication skills
• Proven track record of relationship building
• Collaborative Problem solving
• Strong critical thinking and investigative skills
• Strong time management and organizational skills
• Ability to work independently with minimal oversight
• Proficient in Microsoft Office Suite (i.e., Excel, Word, Outlook).
• Knowledge of Medicare Part B, C & D including HIPAA and compliance regulations

Working Conditions and Additional Requirements (include special requirements, e.g., lifting, travel):

• Must be able to work under normal office conditions and work from home as required.
• Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
• May be required to work additional hours beyond standard work schedule.

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.

Compensation & Total Rewards Overview

We welcome all
All applicants are welcome and will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

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