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MINIMUM QUALIFICATIONS:
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
1. Bachelor's degree
EXPERIENCE:
1.One (1) year of experience working in member/patient experience or management of member/patient complaints and grievances.
PREFERRED QUALIFICATIONS:
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
1. Certification in area of expertise emphasizing the ongoing commitment to continuous learning.
EXPERIENCE:
1. At least three years of patient care experience in either a hospital or health plan setting.
CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.
1. Manages the end-to-end process of complaints and grievances resolution.
2. In collaboration with other members of the Peak Health Management team, works to ensure that complaints and grievances are managed timely.
3. Able to articulates and understands regulatory definitions and requirements within 60 days of hire.
4. Coordinates, monitors, improves, and reports on the progress of cases. Tracks and trends opportunities for improvement with internal and external key stakeholders.
5. Effectively communicates with internal and external stakeholders.
6. Provides functional support to the complaints and grievances clinical review team members.
5. Leads the ongoing cross-functional performance improvement activities related to complaints, grievances, and member experience.
7. Ensures compliance with all state and federal regulatory bodies as well as accreditation agencies.
8. Responsible for implementation of member satisfaction surveys and composing reports as needed to ensure member satisfaction success
PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. Standard office environment
SKILLS AND ABILITIES:
1. Demonstrated knowledge of federal and state laws, NCQA and industry regulations for the management of complaints, grievances, and reporting and improvement of member experience data.
2. Excellent written and oral communication
3. Problem solving capabilities to lead change management
4. Attention to detail
5. Proficiency with the Microsoft Office suite on hire
6Proficiency with the EPIC tapestry system within 90 days of hire.
Additional Job Description:
Scheduled Weekly Hours:
40Shift:
Exempt/Non-Exempt:
United States of America (Non-Exempt)Company:
PHH Peak Health HoldingsCost Center:
2403 PHH Medical ManagementAddress:
1085 Van Voorhis RdMorgantownWest VirginiaEqual Opportunity Employer/Protected Veterans/Individuals with Disabilities.
The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)