Medicaid & CHC Compliance

Serve as a principal administrator for ensuring that all Medical Assistance contractual requirements are accurately communicated throughout the entire health plan and that all Medical Assistance compliance activities are coordinated internally and submitted to DHS (formally DPW) in a timely manner.

Conduct primary and secondary research to prepare accurate and timely responses to internal and external requests for information relating to current and proposed Medical Assistance rules and regulations. Maintain effective tracking and monitoring system for DPW inquires and complaint resolution.

Throughout my years in Complaints and Grievances, I worked as a Specialist, Supervisor and Manager of approximately 19 staff. I was responsible for both Member and Provider appeals for Medicaid, Commercial, Medicare, SNP,CHIP, and Individual Products. Managed timeliness and accuracy complaints and grievances for reporting requirements for regulatory agencies and internal executive staff. Handled tracking, trending, and analysis to determine root cause of appeals and initiate corrective action plans when appropriate.

Assisted Coordinators with resolution of open complaints and grievances. Investigated and responded to appeals for all lines of business, Medicaid, Commercial, CHIP, SNP, Medicare, and Individual plans. Facilitated Second Level Reviews. Worked with regulatory agencies regarding appeals.

Member Services: Helped explain benefits to members and how to utilize services. Provider Contracting Specialist: Worked with sub-contractors to investigate and resolve Member and Provider complaints within 30 day timeframe established by DPW. Authorized benefit exceptions when necessary.