Grievance & Appeals Specialist I

Position Purpose: Responsible for reviewing, investigating and tracking member grievances and appeals, and provider claims disputes. Responsible for coordinating as necessary with the G&A Administrator and outside counsel during state fair hearing proceedings. Responsible for validating, assigning, and completing document folders and records for member grievances and complaints Key Detail: Must reside in the state of Pennsylvania Screen all incoming grievances, appeals and provider claim disputes to ensure they are in compliance with the Arizona Revised Statutes (ARS) and Arizona Department of Health Services (ADHS) / Department of Behavioral Health Services (DBHS) policies and procedures. Coordinate conferences with appropriate parties for appeal proceedings. Conduct grievance investigations through internal and external interviews, inspection of relevant documentation, and interpretation of appropriate legal authorities/policies. Write investigative reports and Notices of Decision or Resolution that meet ADHS/DBHS standards. Provide technical support with respect to Notices of Action. Audit files on an ongoing basis in preparation for quarterly, annual, and ad-hoc audits. Manage daily entries into the DBHS Office of Grievance and Appeals database. Coordinate with all relevant departments, as necessary, to streamline the G&A process. Assist the G&A Administrator and outside counsel in preparation for Fair Hearings. Administer all grievance system processes compet