Job description
Job Summary:
The Grievance & Appeals Compliance Specialist, in collaboration with Corporate Regulatory staff, ensures the Grievance & Appeals (G & A) team is in compliance with contract requirements and accountable that review, submission and required reporting deadlines are met. This role will gather data from a variety of systems (Guiding Care, Facets, RRL, RDM) as part of G&A audit prep and other contract deliverables. This position is full-time, remote.
Essential Functions:
- Manage all operational and administrative issues related to regulatory and government inquiries or complaints as they pertain to G &A; manage relationship with regulatory and reporting groups inside of the CareSource organization
- Provide interpretation and recommendations to G & A in conjunction with the Corporate Regulatory staff regarding regulatory requirements and government contract administration
- Coordinate G & A participation in federal and state contract audits, regulatory audits and site visits
- Provide support to the G & A team in assessing, interpreting, and incorporating new and revised regulatory and government contract requirements into operations
- Serve as liaison for internal and external audits specific to the G & A team
- Report potential risks, non-compliance or alleged violations to the Compliance department
- Ensure policies and procedures are accurate and translate into actionable business decisions
- Perform any other job related duties as requested
Education and Experience:
- Bachelor’s degree in business or related field or equivalent years of relevant work experience is required
- Minimum of three (3) years of managed care, government regulatory and/or contract compliance, or oversight experience is required
Competencies, Knowledge and Skills:
- Intermediate proficiency level with Microsoft Office Suite to include Word, Excel and PowerPoint
- Knowledge of the political and regulatory environments
- Compliance and audit skills
- Ability to prioritize and manage time in a fast-moving environment
- Strong problem-solving skills with attention to detail
- Negotiation skills/experience
- Excellent written and verbal communication skills
- Strong listening and critical thinking skills
- Technical writing skills
- Ability to develop, prioritize and accomplish goals
- Strong interpersonal skills and high level of professionalism
Licensure and Certification:
- None
Working Conditions:
- General office environment; may be required to sit or stand for extended periods of time.
- May be required to travel – estimated at 5%
Organization Level Competencies
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Leveraging Feedback
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Customer Orientation
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Valuing Differences
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Managing Work
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Earning Trust
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Quality Orientation
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Adaptability
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Influencing
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Collaborating
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer, including disability and veteran status. We are committed to a diverse and inclusive work environment.
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