Appeals and Grievances Quality Auditor

Who We Are

Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities.

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.

Key Responsibilities/Duties – what you will be doing

• 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.

Qualifications – what you need to perform the job

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

Commitment to Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity

​Point32Health is committed to making diversity, equity, inclusion, accessibility and health equity part of everything we do—from product design to the workforce driving that innovation. Our Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity team's strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent.  We welcome all applicants and qualified individuals, who 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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