This position is responsible for administering the internal and external claims appeal/grievance processes for Vermont Collaborative Care (VCC). This position also ensures VCC programs comply with NCQA standards and state regulatory requirements. As necessary, the incumbent develops and serves as project manager on initiatives to close compliance gaps.
Regulatory and NCQA responsibilities: (estimated 75%):
Researches and responds to DFR and ombudsman questions.
Acts as liaison to DFR and state ombudsman on VCC related regulatory matters, including participating in state-sponsored work groups and managing internal process for oversight reviews.
Reviews and analyzes state law and NCQA standards to assess areas where VCC policies, procedures, and practices are not compliant with NCQA.
Coordinates with VCC staff to ensure the implementation of compliance programs to include project plan, policies and procedures, and evaluation of program effectiveness. Facilitates action plans and activities related to regulatory and NCQA programs.
Ensure that annual updates to NCQA standards are incorporated into VCC’s business processes.
Work with VCC staff to develop annual work plan, including detailed milestones, to ensure VCC ongoing compliance with NCQA and regulatory standards. Milestones should address both ongoing work and new initiatives.
Track progress on accreditation and regulatory related requirements to enable frequent, timely, and accurate reporting to executive staff. Draft monthly project report for presentation to executive staff.
Ensure VCC program documentation demonstrates full compliance with NCQA and regulatory requirements. Ensure the document is professionally written and suitable for presentation to the board of directors, DFR, and NCQA.
Provide regular updates on regulatory and NCQA compliance to management and oversight committee(s) including risks and mitigation Coordinate VCC’s regulatory and NCQA survey preparation activities, including submission of documents in advance and on-site survey logistics.
Participate in audits by state of Vermont and National Committee for Quality Assurance, working with auditors to identify information needed.
Claims appeal responsibilities: (estimated 25%):
Intakes new cases into the VCC claims appeal process. Maintains the VCC claims appeal docket; sets up, researches, and maintains case files. Prepares hearing file and coordinates appeal review:
Initiates post appeal activities, including adjustments and other actions required by the reviewer decisions.
Prepares notice of decision and manages other communications as necessary with member and provider.
Conducts research and responds to internal and state ombudsman and Vermont Department of Financial Regulation (DFR) inquiries and complaints, external appeals, and inquiries from attorneys in coordination with BCBSVT legal department.
Identifies issues found during appeal research and review process, and assists with resolution of such issues when appropriate.
Works with BCBSVT legal department to develop and maintain all processes and procedures of the VCC claims appeal process in an appropriate, effective, and efficient manner.
Maintains databases and reports on the claims appeal/grievance process to include but not limited to:
DFR grievance tables (reported annually)
Internal file audits (at least twice annually needed)
Regulatory file audits (as needed)
Internal quality checks on database entries (monthly and/or quarterly)
Conducts annual review of departmental reports, policies, and desk procedures to include but not limited to:
VCC appeal policy and desk procedure(s)
VCC external appeal policy and desk procedure(s)
VCC Mental Health Review Agent Report
VCC Mental Health License Renewal
Handles matters requiring the highest level of confidentiality
Reports on appeal activity and trends.
Bachelor’s degree in a health related field with solid experience in a health business setting and minimum of 3 years experience in health related field (health plan experience a plus)
Demonstrated ability to manage projects
Working knowledge of managed care programs
Experience with regulatory and accrediting standards
Project management, presentation, and written communication skills.
Experience with managing multiple tasks
Strong analytical skills
Ability and willingness to travel
Strong writing and presentation skills
Strong communication skills for internal relationship building and external member/provider relations