Customer Service Due Process Manager at Detroit Wayne Integrated Health Network – Detroit, Michigan

Customer Service Due Process Manager

Detroit, MI, US

Job Details

Under the supervision of the Customer Service Administrator, the Customer Service Due Process Manager is responsible for managing and assuring that the DWIHN’s member grievances and appeals processes are carried out in accordance with local, state and federal regulations, BBA, Mental Health Code mandates

PRIMARY DUTIES AND RESPONSIBILITIES:

Provide applicable Customer Service information, referral, linkage, and follow through for telephone and walk-in inquiries. Enforces all due process policies as it pertains to Grievances, Appeals, Local Appeals Dispute Resolutions, and Mediation inquiries.Advances the grievances and appeals processes and procedures in accordance with Medicare Federal Rules, Medicaid MDHHS guidelines, Michigan Mental Health Code, NCQA requirements, Integrated Care Organizations, and DWIHN policies and procedures.Supervises the Grievances and Appeals staff. Oversees the monitoring of the grievances and appeals processes and contractor network to ensure compliance with established policies and procedures. Collaborates and coordinates with all DWIHN units on dispute resolutions as deemed necessary to ensure that issues are addressed in accordance with regulatory guidelines, mandated policies, and procedures. Develops and maintains a system that tracks and monitors grievances, appeals, State Fair Hearings, and Mediations, including final dispositions for all DWIHN product lines.Reviews and analyzes grievance and appeal data and reports to identify trends and patterns.Provides monthly, quarterly, and annual Due Process reports on grievances, appeals, fair hearings, mediation, and dispute resolutions activities.Provide technical assistance to DWIHN staff and contractors on grievances, appeals processes, and applicable dispute resolution protocols.Facilitates State Administrative Hearing /Medicaid Fair Hearing process.Oversees the development and implementation of on-going grievance and appeal training modules specific to applicable audiences i.e., DWIHN staff, contracted providers, enrollees, and family members.Oversees the development and maintenance of grievances and appeals educational information and materials (i.e. handbook, posters, brochures, forms, policies etc.).Oversees the facilitation of periodic meetings with contractor Grievances and Appeals Coordinators to address DWIHN updates and issues applicable to due process activities.Develop DWIHN and contractor Grievances and Appeals compliance monitoring review tools in accordance with Federal, State, Local requirements, and DWIHN policies.Participates as a member of the Customer Service Management team.Attends applicable DWIHN-related meetings.Other related duties as assigned.

KNOWLEDGES, SKILLS, AND ABILITIES:

Supervisory and/ or managerial skillsStrong analytical skillsKnowledge of grievances, appeals, and dispute resolution regulations and legislation. Advanced knowledge in interviewing, investigation, and report writing skills. Ability to effectively analyze, mediate, and solve problems.Ability to effectively communicate in writing and orally.Excellent presentation skills.Advanced skills in database management, tracking, and reporting. Advanced skill level in computer applications, i.e., Microsoft Word, Excel, Project, and PowerPoint.Ability to maintain data files and other records.Strong organizational skillsAbility to multitask.Ability to work effectively independently and in a team structure.Excellent customer service skills

Training: (Education)

Minimum of a Bachelor’s Degree from a recognized college or university in Psychology, Social Work, or a related area.

Experience

At Least five (5) years of full-time paid professional experience in complex cross-functional grievance/appeal/dispute resolution and/or enrollee relations.

WORKING CONDITIONS: (Environment in which most work is performed)

Work is usually performed in an office setting, but may require the employee to drive to different sites throughout Wayne County.

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified.

DWIHN is an Equal Opportunity Employer