Clinical Reviewer, Medicare Complaints, Appeals & Grievances (MCAG)

Sonder Health Plans Atlanta, GA (Remote)

Salary Range: $70,000 - $99,000 /yr # of positions: 1

Job Summary
Responsible for reviewing and resolving Medicare complaints/appeals and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid (CMS) and internal clinical policy guidelines.

Knowledge/Skills/Abilities

• Responsible for review, intervention and resolution of clinical complaints, appeals and grievances from Sonder members and related outside agencies, while maintaining confidentiality. May assist with non-clinical cases as needed.
• Ensures all cases have been organized, categorized and documented thoroughly and correctly.
• Prioritizes and organizes tasks to meet compliance deadlines.
• Researches issues utilizing systems and clinical knowledge and approved "Decision Support Tools" in the decision making process.
• Requests and reviews complaint information from both Providers and Members including but not limited to, detailed bills/claims submissions, arguments for benefit coverage, medical records, benefit materials and internal/external systems as appropriate.
• Evaluates for benefit coverage; formulates conclusions per protocol and collaborates with other clinical staff, Medical Directors and other team members to determine response as appropriate.
• Analyzes work processes and identifies areas where procedures and quality could be improved
• Identifies root cause of complaints and provides applicable feedback to minimize member abrasion.
• Assures timeliness and appropriateness of responses in accordance with state, federal and Sonder Health Plans’ policies and procedures.
• Prepares complaints, appeals and grievance summaries, correspondence and documents information for tracking/trending data; assists in the preparation of case files to external review entities.
• Ability to meet established productivity, schedule adherence, and quality standards.
• Communicates with the management team to correct problems ensuring customer satisfaction.
• Reliably and consistently meets work schedules, productivity requirements and deadlines.
• Attends meetings as required; Participates in employee orientation and training.
• Performs and assists in other duties and special projects as required.
• Researches and applies appropriate clinical criteria; ability to research and identify appropriate peer reviewed medical literature as needed.
• Requires communicating directly (verbally and in writing) with members and providers to obtain relevant information and inform of decisions and next steps

Required Education

• RN - Will consider LPN with applicable experience/references

Required Experience

• Medicare Managed Care complaints, appeals and grievances or utilization management experience

• Excellent research skills
• Understanding of computer programs including but not limited to Microsoft Office and other related applications as well as ability to navigate CMS and state websites and systems as applicable
• Ability to work independently and collaboratively with cross-functional teams in a highly matrixed organization

Preferred Education/Experience

• Associates Degree in Nursing (ASN) or Bachelor of Science in Nursing (BSN) degree or higher
• Preferred completion of other healthcare related vocational programs/certifications (e.g., Certified Coder, billing)
• 2+ years’ experience working with Medicare Advantage requirements and Clinical Policies preferred
• Preferred experience/participation in CMS and State Audits as well as experience with all levels

of the Medicare appeals process (ALJ, QIO, QIC)