Provider Network Specialist jobs in Hamden, CT

Community Health Network of Connecticut, Inc. (CHNCT) is currently seeking an Appeals and Grievances Specialist.

Primary Responsibilities: 

• Under the direction of the Manager of Appeals and Grievances, the Appeals and Grievances Specialist is responsible processing provider reevaluation requests, providing collaborative support for the Appeals and Grievance Analysts in processing member appeals and for investigating quality of care (QOC) matters identified through the Grievance process. 
• All functions are conducted in accordance with the Department of Social Services (DSS) contractual requirements and URAC standards.

Tasks Performed: 

• Independently processes all aspects of provider requests for reevaluations, provides support for processing member appeals, and conducts clinical investigations/chart reviews for QOC matters identified in the Grievance process.
• Collaborates with Medical Reviewers as needed for these functions. 
• Communicates with members and providers, enters information in the care management system, generates and edits letters. 
• Ensures compliance with DSS and URAC requirements.

Essential Functions: 

• Comprehensive processing of provider reevaluations. Clinical investigation of all aspects of QOC issues identified through the grievance process. 
• Collaboration within the Appeals and Grievance Department, cross-functional collaboration as needed. 
• May support the member appeal process. Identifies barriers in coordination of care and makes referrals to care management as needed. 
• Identifies quality issues and makes referrals to quality management.

Desired Education: Two years post-secondary schooling

Desired Degree: Associate's degree preferred

Desired Major:  Nursing

Desired Job Experience: Working knowledge of HUSKY programs a plus. Minimum of 1 year experience processing member or provider appeals, grievances and/or conducting clinical investigations a plus. Proficient with computers, data entry, Microsoft Excel, Word, Outlook.

Other Qualifications: Strong clinical background, Excellent organizational skills, ability to manage multiple priorities concurrently. Strong oral and written communication skills with ability to effectively communicate with members and providers and escalate matters as appropriate. Ability to simplify medical and benefit language so that it is easy to understand. Strong computer and keyboard skills. Team player and excellent cross functional collaboration skills. Ability to prioritize work and exercise independent and sound judgement in decision-making. Managed care experience preferred. Knowledge of Medicaid preferred. Connecticut LPN license must be current and unrestricted.

Certifications Required: Active Licensed Practical Nurse License

CHNCT is an equal opportunity, affirmative action employer m/f/d/v and proud of the diversity of our workforce. 

Important Note to Applicants:  CHNCT as a company feels very strongly that we need to do what we can to help control the spread of COVID-19 infections. Therefore, all employees, contractors, consultants and agency temporary staff are required to be fully vaccinated to work at CHNCT. Reasonable accommodations for medical or religious exemptions will be provided with appropriate documentation for positions that do not have in-person/member visitation requirements.