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Medicare Appeals and Grievances Compliance Auditor

Job Description:

Primary Responsibilities (Include duties that represent 5% or more of employee’s time)

  • Leads and represents Member Appeals and Grievances-related external CMS audits, NCQA Standards, state audit and/or internal audit.
  • Facilitates and completes internal dashboards and universes for accuracy and timeliness.
  • Conduct audits on a regular basis according to the policies and procedures as assigned by the Director. Perform root cause analysis to ensure accuracy of departmental processes and identify, when needed, process improvement opportunities. Produce any necessary Corrective Action Plans, Mitigation strategies and associated impact analysis.
  • Through quality control and departmental audits, is responsible for identifying gaps in our procedures as they relate to our internal audit practices, and escalates concerns to management.  Must have the ability to analyze various situations and be able to make independent decisions on best practices in the interest of the members and the health plan to remain within compliance.
  • Participates in various meetings as a department representative; acts as a representative on various company wide committees. Dessimates policies and procedure information to staff to ensure successful functioning of the Department. Research and resolve system-wide issues, deficiencies, problems and formulate quality improvement measures.
  • Meet regularly with Department Director and management team to identify and discuss department and/or identified system issues directly effecting member and staff satisfaction to recommend plans for improvement measures and in developing and implementing specific work plans for improvements in department work processes.
  • Propose and participate in training based upon audit results and trending. Ensures operating manuals and procedural documents stay current when regulations change.
  • Ensure adherence to Plan’s Standard and Expedited Appeals and Grievances processes as outlined in Member Handbook/Evidence of Coverage, and in compliance with applicable NCQA standards, CMS, MassHealth and other state or federal regulatory requirements.
  • Performs other duties as they are assigned to meet department performance goals and to respond to changing priorities including administrative related tasks.

Working Conditions

  • While performing the duties of this job, the employee works in normal office working conditions.

Disclaimer: The job description describes the general nature and level of work being performed by people assigned to this job and is not intended to be an exhaustive list of all responsibilities, duties and skills required. The physical activities, demands, and working conditions represent 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 job duties and responsibilities.


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Medicare Appeals and Grievances Compliance Auditor

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