Meridian

  • Appeals and Grievance Team Lead

    Job Location US-MI-Detroit
    Job ID
    2018-5488
    Category
    Pharmacy
    Business Line
    MRx
  • Overview

    Who we are:

     

     

    MeridianRx is a full-service Pharmacy Benefit Manager (PBM) committed to driving down costs and elevating quality. Our clients experience better quality outcomes, thanks to effective clinical support, patient education, and specialty pharmacy programs. 

    We work with a diverse range of clients, from members to healthcare providers to plan administrators. MeridianRx services clients across the country and our network continues to grow.  

    Our employees work hard, play hard, and give back. MeridianRx employees enjoy: Happy hours, special events, company sports teams, potlucks, Bagel Fridays, and volunteer opportunities.

    A Day in the Life of a Appeals and Grievance Team Lead:

     

    This position is responsible for oversight of the Appeals and Grievances for MeridianRx and SentinelRx. Successfully maintains National Committee for Quality Assurance (NCQA), URAC and/or general accreditation status with regard to appeal and grievances processes. This position ensures the team has efficient processes built to meet production standards and deliver quality care.    

    Responsibilities

    • Responsible for managing all administrative aspects of the appeal processes within the department to promote consistency and accuracy within the processes and compliance with NCQA, URAC or general accreditation, regulatory requirements and HIPAA guidelines
    • Work closely with Manager of Clinical Support to act as a liaison between clinical pharmacists and MHP Appeals and Grievance team
    • Ensures staff meet all relevant regulatory requirements, comprehends and complies with best practices, professional standards, internal policies, and procedures
    • Supervises, analyzes and coordinates the daily activities to ensure departmental goals are met with regards to timeliness, accuracy and consistency of medication coverage decisions
    • Responsible for providing expertise or general support in reviewing, researching, investigating, negotiating and resolving all types of grievances, State complaints, and/or escalated issues
    • Supervises the training of new staff
    • Daily prioritization of workflow assignments for optimizing impact on department production and timeliness
    • Perform weekly quality audits for appeals and grievance staff and addressing failed audits with family members to provide guidance and performance improvement
    • Prepares, with the department analyst and/or manager, client appeals, grievance and complaint reports regularly and/or as needed
    • Oversee collaboration and investigations with other departments as necessary (Member Services, Network Development, Claims, Utilization Management, Medical Management and Pharmacy) to ensure the timely resolution of all appeals and grievances
    • Recognize opportunities to improve the quality of care/services and activities to continually strive to improve outcomes
    • Responsible for reviewing and editing grievance, denial, and appeal decision letters to ensure accuracy
    • Oversee intake/triage and appropriate classification of Appeals, Grievances, and State Fair Hearing and External Review requests and follows procedures on how to handle each type of request and route to the appropriate area within the department timely
    • Oversight of all external review to ensure timeliness of data submission and follow through of cases (ex. State Fair Hearings, External Independent Review, etc.)
    • Responsible for coordination and presentation of information for administrative hearings and state external reviews
    • Oversee the preparation work for each hearing, EIR request to ensure deadlines are met and supporting pharmacists to gather information required for additional review
    • Daily prioritization of workflow for optimizing impact on department production
    • Works with the IT department on MCS and Merlin development issues as it pertains to grievances and appeals
    • Prepares, with the department assistant, each second level medical necessity Pre-Service appeal for review by the appeals committee. Materials are prepared when the call to the member is placed
    • Assists the Appeals & Grievance Coordinators and Clinical Operations Leadership with the member complaints that involve clinical issues
    • Updates Pharmacy departments and provide training of relevant changes to the appeal policy and procedures as needed
    • Oversee case investigates relevant to pharmacy medication complaints; researches and provides written summary to as needed
    • Provide ongoing training and education to the staff through one-on-one and classroom settings regarding criteria, processes, and regulatory requirements and other necessary job-related skills
    • Utilize professional knowledge, MHP/MRx knowledge and pertinent resources or use the appropriate reporting structure to solve problems and issues as identified
    • Works with department manager to schedule PTO time for department staff
    • Responsible for maintaining and updating annually at a minimum: appeal and grievance policies and procedures, member correspondence materials, and process manuals consistent with regulatory or contractual changes
    • Perform other duties as assigned

    Qualifications

    • Registered Pharmacy Technician who has successfully completed a Certified Pharmacy Technician training program is strongly preferred. Enrollment and gaining CPhT licensure within 12 months of hire date is required.
    • Nationally Recognized Certification and full license in applicable state is required within 12 months of hire date. Limited and temporary licensures are not acceptable
    • License and certification must be in good standing
    • Two to five years of experience in pharmacy or health care related field required
    • Experience in projects involved with State and Federal regulations, and compliance strongly preferred.
    • One to three years of leadership experience strongly preferred
    • Knowledge of drug products, dosage forms and usage, as well as retail pharmacy operations is preferred.
    • Familiar with clinical program components, formulary designs, and prescription drug benefit trends
    • Knowledge of Medicare and Medicaid guidelines, medical necessity and benefit structure
    • Knowledge of NCQA, URAC or general accreditation requirements and guidelines for utilization management, denials appeals and grievances
    • Demonstrated leadership skills
    • Excellent organizational and critical thinking skills
    • Detail-oriented with strong organizational skills
    • Excellent written and verbal communication skills
    • Demonstrated clinical knowledge and expertise
    • Excellent customer service and interpersonal communication skills; maintains professional demeanor
    • Computer/data entry skills; proficient in data warehouse, database, word processing and spreadsheet application
    • Ability to prioritize work load
    • Ability to work collaboratively and effectively with diverse groups
    • Ability to function as part of an interdisciplinary team
    • Ability to prioritize and coordinate member care needs
    • Ability to work with minimal management oversight on multiple projects with competing priorities
    • Ability to prioritize work and function under time constraints
    • Ability and desire to work in a team atmosphere
    • Ability to work as part of a team while meeting individual goals and objectives
    • Ability to identify, develop and implement process improvements

     

    What Meridian can offer you:

    • Healthcare benefits that include a variety of plans, which are effective on the first day of employment for our new full-time team members.
    • Opportunity to work with the industry’s leading technologies and participate in unique projects, demonstrations, conferences, and exclusive learning opportunities.
    • 401k matching that is above the national average.
    • Full-time MeridianRx employees are eligible for tuition reimbursement towards Bachelor’s or graduate degrees.
    • A bright and engaging company culture; the Meridian family of companies has been recognized as one of Metro Detroit’s Best and Brightest Companies to Work For 5 years in a row.


    Equal Opportunity Employer

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