Appeals and Grievances Quality Control Trainer (QCT) - Care N’ Care (CNC) Health Plan - Southwestern Health Resources (SWHR)

Here’s What You Need

Education

• High School Diploma or equivalent required.

Experience

• Require 2 years’ experience in Customer Service, Sales, Account Management, Quality Monitoring or Training experience.
• Require 1 year experience in Medicare organization determination, appeals, and grievance case processing or auditing.

Skills & Abilities

• Thorough knowledge of CMS guidelines, process and systems.
• Strong attention to detail, accuracy and be well organized.
• Excellent problem-solving skills and capacity to navigate stressful situations with ease.
• Strong interpersonal communication skills.
• Ability to work independently or as a team.
• Proficient with Microsoft Office (Excel, Word, Power Point)

What You Will Do

Position Responsibilities

The Appeals and Grievances Quality Control Trainer is responsible for ensuring the health plan and its partners adhere to CMS regulations and processing timeframes for all organization determinations, appeals and grievances through regular quality control and case auditing activities. This position is also responsible for onboarding new staff and continuous training and coaching of the Appeals and Grievances team.

Position Functions

• Perform audits of organization determination, appeal, and grievance cases to ensure the health plan and its partners are adhering to Medicare regulations and processing timeframes.
• Evaluate and implement methods to improve efficiency and service to both internal and external customers.
• Ensure the health plan and its delegated entities/partners maintain audit readiness through internal and external audits and attestations.
• Create and maintain department policies and procedures, forms, and educational documents.
• Participates in the development of compliance training and department educational materials.
• Coordinate onboarding and departmental training of new staff.
• Educate the staff on department policies and procedures, process improvements, and Medicare regulations pertaining to organization determination, appeal, and grievance case processing.
• Meets weekly with team leadership offering suggestions for gaps identified within case monitoring and auditing.
• Assistance with daily tasks as necessary for maximum performance of business operations including working appeal and grievance cases.
• Assist with audit and/or corrective action plan (CAP) responses to ensure they adequately address the root cause of issues/incidents.
• Assist the Operations Manager in working with internal analysts to improve report design and to ensure compliance with CMS regulations.
• Maintain a strong knowledge of Medicare regulatory requirements and the ability to analyze and interpret federal and state laws and regulations.
• Maintain a strong understanding of all Appeals & Grievance team processes and procedures and identify and report trends in gaps by case monitoring.

Why Southwestern Health Resources 

As a Southwestern Health Resources employee, you’ll enjoy, comprehensive benefits, including a 401(k) with match; paid time off; competitive health insurance choices; healthcare and dependent care spending account options; wellness programs to keep you and your family healthy; tuition reimbursement; a student loan repayment program; and more.

• Additional perks of being an SWHR employee:
• Gain a sense of accomplishment by contributing to a teamwork environment.
• Positively impact patients’ quality of life.
• Receive excellent mentorship, comprehensive training and dedicated clinical and administrative leadership resources.
• Enjoy opportunities for growth.

Explore Southwestern Health Resources Careers for more information and to search all career opportunities.

Our Recruitment team invites you to contact us with any questions at recruitment@texashealth.org