Appeals and Grievances Quality Control Trainer (QCT) – Care N’ Care (CNC) Health Plan – Southwestern Health Resources (SWHR)

Appeals and Grievances Quality Control Trainer (QCT) – Care N’ Care (CNC)

Care N ‘Care Health Plan is looking for top skilled Appeals and Grievances Quality Control Trainer (QCT). Is that you?

Work location: Southwestern Health Resources Headquarters, 1601/1603 Lyndon B. Johnson Freeway, Farmers Branch, TX 75234.

Work environment: Care N’ Care Health Plan Department.

Please note: The Appeals and Grievances Quality Control Trainer (QCT) – Care N’ Care (CNC) will be an employee of Southwestern Health Resources (SWHR). SWHR is a clinically integrated network formed by Texas Health Resources (THR) and University of Texas Southwestern Medical Center (UTSW).

Work hours:

• Full Time; 40 hours per week.
• Monday – Friday. Day shift.
• This is a Hybrid position, requiring occasional onsite workdays based on department business needs.
• In-person attendance required at department meetings, trainings and/or other department authorized activities, at the above-mentioned address or other locations as directed by the department management.

Organization Highlights

Southwestern Health Resources (SWHR) is a patient-centered, clinically integrated network of 31 hospital locations and more than 7000 physicians and clinicians caring for more than 790,000 patients across 16 counties in North Texas. Blending the strengths of Texas Health Resources and the University of Texas Southwestern Medical Center, SWHR offers an unmatched ability to connect individuals with a full spectrum of nationally preeminent, clinical care. SWHR is the parent of Care N’ Care Insurance Co., a leading regional Medicare Advantage health plan that serves North Texas seniors.

At SWHR, we believe healthcare can be more integrated, accessible and affordable for all. Our purpose: to build a better way to care, together. Our promise: to simplify and empower care, for good.

Here’s What You Need

Education

• High School Diploma or equivalent required.

Experience

• Require 2 years’ experience in Customer Service, Sales, Account Management, Quality Monitoring or Training experience.
• Require 1 year experience in Medicare organization determination, appeals, and grievance case processing or auditing.

Skills & Abilities

• Thorough knowledge of CMS guidelines, process and systems.
• Strong attention to detail, accuracy and be well organized.
• Excellent problem-solving skills and capacity to navigate stressful situations with ease.
• Strong interpersonal communication skills.
• Ability to work independently or as a team.
• Proficient with Microsoft Office (Excel, Word, Power Point)

What You Will Do

Position Responsibilities

The Appeals and Grievances Quality Control Trainer is responsible for ensuring the health plan and its partners adhere to CMS regulations and processing timeframes for all organization determinations, appeals and grievances through regular quality control and case auditing activities. This position is also responsible for onboarding new staff and continuous training and coaching of the Appeals and Grievances team.

Position Functions

• Perform audits of organization determination, appeal, and grievance cases to ensure the health plan and its partners are adhering to Medicare regulations and processing timeframes.
• Evaluate and implement methods to improve efficiency and service to both internal and external customers.
• Ensure the health plan and its delegated entities/partners maintain audit readiness through internal and external audits and attestations.
• Create and maintain department policies and procedures, forms, and educational documents.
• Participates in the development of compliance training and department educational materials.
• Coordinate onboarding and departmental training of new staff.
• Educate the staff on department policies and procedures, process improvements, and Medicare regulations pertaining to organization determination, appeal, and grievance case processing.
• Meets weekly with team leadership offering suggestions for gaps identified within case monitoring and auditing.
• Assistance with daily tasks as necessary for maximum performance of business operations including working appeal and grievance cases.
• Assist with audit and/or corrective action plan (CAP) responses to ensure they adequately address the root cause of issues/incidents.
• Assist the Operations Manager in working with internal analysts to improve report design and to ensure compliance with CMS regulations.
• Maintain a strong knowledge of Medicare regulatory requirements and the ability to analyze and interpret federal and state laws and regulations.
• Maintain a strong understanding of all Appeals & Grievance team processes and procedures and identify and report trends in gaps by case monitoring.

Why Southwestern Health Resources

As a Southwestern Health Resources employee, you’ll enjoy, comprehensive benefits, including a 401(k) with match; paid time off; competitive health insurance choices; healthcare and dependent care spending account options; wellness programs to keep you and your family healthy; tuition reimbursement; a student loan repayment program; and more.

• Additional perks of being an SWHR employee:
• Gain a sense of accomplishment by contributing to a teamwork environment.
• Positively impact patients’ quality of life.
• Receive excellent mentorship, comprehensive training and dedicated clinical and administrative leadership resources.
• Enjoy opportunities for growth.

Explore Southwestern Health Resources Careers for more information and to search all career opportunities.

Our Recruitment team invites you to contact us with any questions at [email protected]