Grievance and Appeal Manager

<strong>By joining Region 10, you can help actualize our mission of promoting opportunities for recovery, discovery, health and independence for individuals receiving services through ease of access, high quality of care and best value.&nbsp; View the details below on how you can become a Grievance and Appeal Manager for Region 10 PIHP</strong>

Port Huron, MI

Region 10 PIHP

<p>Region 10 Prepaid Inpatient Health Plan Provides public services for mental health and substance use disorders through the Community Mental Health agencies in Genesee, Lapeer, Sanilac and St. Clair counties and a panel of other care providers.</p> <h4>Mission: Promoting opportunities for Recovery, Discovery, Health and Independence for individuals receiving services through ease of access, high quality of care and best value.</h4>

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$56,950.00 / Year

Overview: <p>An employee at this level is required to perform some or all of the following duties, which do not include all tasks to be performed:</p> <p>Grievance and Appeal:</p> <p>Overall Provider Network</p> <ul> <li>Oversee and administer the Region 10 PIHP Grievance and Appeal System for Medicaid Enrollees</li> <li>Utilize PIHP Electronic Medical Record (EMR) software to document and maintain electronic files</li> <li>Meet with lead PIHP Clinical Staff related to specific case review</li> <li>Resolve enrollee appeals or grievances within the applicable timeframes required by federal regulations</li> <li>Serve as PIHP liaison for all Medicaid State Fair Hearings&nbsp;</li> </ul>
Responsibilities: <div>SUD Provider Network</div> <ul> <li>Receive complaints and grievances from enrollees within the SUD network and work toward resolution between the enrollee and provider within the required timeframes</li> <li>Serve as the regional rights advisor for the SUD network</li> </ul> <div>CMH Provider Network</div> <ul> <li>Receive monthly grievance reports from each CMH and maintain a database of Medicaid grievances filed in the region</li> <li>Maintain records of grievances, appeals and state fair hearings filed for the region in each quarter and produce reports for presentation to the PIHP board.</li> <li>Advise Chief Executive Officer and Management Team on relevant issues</li> <li>Serve as the Medicaid Fair Hearing Officer for the region</li> </ul> <p>Customer Service:</p> <ul> <li>Coordinate and oversee provision of MDHHS Customer Service requirements</li> <li>Complete timely review and necessary follow up on any case review requests submitted by MDHHS or other entities to the PIHP</li> </ul> <p>Compliance:</p> <ul> <li>Coordinate and administer the Region 10 PIHP Compliance System</li> <li>Meet with regional Corporate Compliance Officers</li> <li>Review data and reports related to Corporate Compliance complaints</li> <li>Corporate Compliance Complaint Review &amp; Investigation</li> </ul>
Requirements: <p>Minimum Qualifications:</p> <ul> <li>Master&rsquo;s Degree</li> <li>Experience working at Pre-Paid Inpatient Health Plan (PIHP) and/or Community Mental Health (CMH)</li> <li>Excellent organizational skills</li> <li>Excellent writing skills</li> <li>Demonstrated knowledge of State of Michigan Medicaid Provider Manual</li> <li>Demonstrated knowledge of MDHHS-PIHP contract language</li> <li>Demonstrated knowledge of Microsoft Word and Excel</li> <li>Ability to exercise some flexibility in problem solving, when expected results are clear and generally set by others, provided certain outcomes are avoided</li> <li>Ingenuity is required to adapt, alter, or improvise alternatives when unexpected situations occur</li> <li>Ability to exercise discretion and some flexibility in selecting an optimal solution from established alternatives to obtain the desired outcome</li> <li>Ability to use or exert influence in a work process</li> <li>Ability to be a &ldquo;work leader&rdquo; (of a person or function), or advise others</li> <li>Ability to provide, exchange, or explain information which conveys an opinion or evaluation of the facts or analyses</li> <li>Ability to develop and/or maintain effective work relationships with new, established, or non-receptive individuals/organizations through tact, diplomacy and persuasion</li> <li>Valid State of Michigan Driver&rsquo;s License</li> <li>Must have access to transportation</li> </ul> <p>Preferred Qualifications:</p> <ul> <li>Five years&rsquo; experience working with Pre-Paid Inpatient Health Plan</li> <li>Five years&rsquo; experience working in an administrative capacity at Community Mental Health (CMH)</li> <li>Experience working with Substance Use Disorder Coordinating Agency / Providers</li> </ul>