PRIMARY FUNCTION:The Grievance and Appeals Coordinator is responsible for day-to-day management of South Country Health Alliances (SCHA) procedures for grievances, including quality of care, health plan appeals, State Fair Hearings and those that proceed to litigation for the Prepaid Medical Assistance Program (PMAP), General Medical Assistance (GMAC), Minnesota Care (MNCare), AbilityCare and Minnesota Senior Health Options (MSHO)/ MSC+ Products. This includes assessing the appropriateness for determinations made on appealed clinical and non-clinical benefit determinations and benefit exceptions requests. Under limited supervision, this person will perform advanced and complicated case review duties requiring clinical judgment, independent analysis and detailed knowledge of departmental and regulatory procedures. __________________________________________________MINIMUM QUALIFICATIONS OF EDUCATION & EXPERIENCERegistered Nurse with an active license in the State of Minnesota requiredB.A or B.S in Nursing preferredBroad-based clinical background3-5 years health care experience required, preferably with some health plan experienceAbility to work independently Critical thinking skillsInvestigative and creative problem-solving skillsKnowledge of federal and state regulatory requirements for appeals and grievancesExperience in Microsoft Office, especially Word and ExcelExcellent written and verbal communication skillsAbility to work with Third-Party Administrators, health care providers and professionalsAbility to work across SCHA departments, particularly Care Coordination and Health ServicesOrganizational and time management skillsAvailable to travel to occasionally to meet business needs, if requiredDESIRABLE QUALIFICATIONSMedical Surgical ExperienceUnderstanding of the County health care structure__________________________________________________ESSENTIAL DUTIES AND RESPONSIBILITIES:Grievances, Appeals and State Fair Hearings:Receives and reviews member grievances and appeals. This may involve management of members in the midst of a treatment plan or requiring acute or chronic care. Acquires appropriate documents for case review, including but not limited to applicable laws, rules and regulations, Certificate of Coverage/ Evidence of Coverage, SCHA Policies, medical records and other pertinent information.Researches and documents case history in compliance with process and policy for grievances, appeals, State Fair hearings and regulatory agency inquiries. This includes reassessment of the appropriateness of initial or appealed determinations and the upholding or reversing previous determinations. Coordinates documented clinical and non-clinical review working in partnership with the Medical Director, Care Coordination Director, Medical Services Director, county staff and network providers to ensure timely and appropriate resolution for the member and member rights are protected. Reviews content of grievance or appeal and investigates potential quality of care and service issues through written and/or telephonic contact with providers and SCHA Medical Director. Cases are reviewed according to policies and guidelines established and may require referral to appropriate department for follow through of corrective action plans. This person researches any complaints from Department of Human Services and Minnesota Department of Health for any clinical or service quality issues. Summarizes case including member perception, analysis of medical records and pertinent information, applicable laws and regulations, and SCHA policies and presents information to Medical Director for decision-making. Prepares questions on grievance and appeal cases for consultant and external party medical review.Analysis of case review results and trends, which may be identified through review of appeal/grievance cases, including prioritizing and developing appropriate action plans for resolution of issues.Notify Compliance Officer immediately if a state or federal regulatory makes an inquiry regarding policies or procedures for appeals or grievances. Monitors consistency and quality of process, determinations and timeliness to comply with state and federal regulations.Communicates with third-party administrators regarding reviewing and handling of grievances, appeals and State Fair Hearings.Oversees operations infrastructure to support the processes required in handling grievances, appeals and State Fair Hearings.Documents in CCM thorough, accurate and timely cases documentation, tracking and resolution. Oversees the establishment of operational infrastructure to support the processes required in handling grievances, appeals and State Fair Hearings.Implement and monitor clinic complaint tracking system. Benefit ExceptionsReceives and reviews member benefit exceptions. Acquires appropriate documents for case review, including but not limited to applicable laws, rules and regulations, Certificate of Coverage/ Evidence of Coverage, SCHA Policies, medical records and other pertinent information.Researches and documents case history in compliance with process and policy for benefit exceptions. Coordinates documented benefit exception review working in partnership with the Medical Director, Care Coordination Director, Medical Services Director, county staff and network providers to ensure timely and appropriate resolution for the member and member rights are protected. Documents in CCM thorough, accurate and timely cases documentation, tracking and resolution. Oversees the establishment of operational infrastructure to support the processes required in handling benefit exceptions.Other job duties as assigned within the scope, responsibility and requirements of the job.GENERAL DUTIES AND RESPONSIBILITIES WITHIN SCHA:Work as a team with SCHA staff and county staff.Promotes SCHA policies and mission in performing all duties and responsibilities.Incorporates best practice into all process initiatives.Ensures department operations support SCHA compliance and quality management initiatives.