Job Description

Position Purpose: The Grievance and Appeals Administrator (Manager) is responsible for oversight of the full grievances and appeals process for SHCA members. This position further ensures compliance with member rights including notices and decisions as required by law and AHCCCS policy. The Grievance System Administrator is prohibited from acting as or under the supervision of in-house legal counsel, retained legal counsel corporate counsel or risk management attorney. This position requires the employee to reside in Arizona within the assigned Geographical Service Area in Greater Arizona.

  • Manages, oversees, implements and administers all aspects of the grievance and appeals system processes consistent with AHCCCS requirements for members, subcontractors and providers.
  • Processes grievances and appeals for members and providers in accordance with AHCCCS guidelines in a timely, accurate manner consistent with law and Contract requirements and terms.
  • Investigates and processes grievances and appeals in accordance with administrative regulations and state requirements including coordination with SHCA clinical and legal staff and SHCA providers.
  • Prepares legal memoranda regarding decisions and represents SHCA at state fair hearings regarding decisions, Title XIX, and claims appeals.
  • Reviews, analyzes, compiles data, recommends and reports on individual and agency providers to the Chief Executive Officer, the Chief Medical Officer, the Integrated Leadership Quality Council, the Integrated Quality Management Committee, the Integrated Provider Advisory Committee, Quality Management Department and AHCCCS as appropriate and required.
  • Reviews analysis and data compilation as it applies to individual grievances and, monitors trends over time.
  • Reviews and revises policies and procedures in collaboration with SHCA Executive Leadership and AHCCCS to ensure accurate and consistent application of AHCCCS requirements.
  • Provides technical assistance and/or training to providers and SHCA staff regarding grievances, appeals, and Notice of Action processes in accordance with AHCCCS requirements.
  • Participates on SHCA Quality Management Committee and other committees and workgroups as needed.
  • May supervise employees including establishing performance goals, conducting performance appraisals, monitoring work and performing discipline as needed.
  • Performs other duties of a similar nature and level as assigned.

Education:

  • Must hold a juris doctor degree from an accredited institution with experience in behavioral health investigations and mediations/alternative dispute resolution.
  • The individual must have the ability to obtain Council on Licensure, Enforcement and Regulation (CLEAR) certification.

Years of Experience:

  • At least 2 years’ experience in managed care and/or legal services, or a combination of experience and education

Specialized Knowledge:

  • Knowledge of laws, rules, regulations, policies, and legal practices related to health and behavioral health, and managed care,
  • Knowledgeable of and maintain compliance with AHCCCS contract requirements as related to the job responsibilities outlined within the job description.
  • Valid Arizona Drivers’ License as some travel may be required
  • Excellent Written and Oral Communication Skills
  • High proficiency with MSWord application
  • Excellent communication and collaboration skills.
  • Excellent customer service and oral/written communication skills
  • Demonstrated attention to detail and accuracy.
  • Demonstrated organizational skills.
  • Excellent problem solving, information/research skills.
  • Ability to use electronic word processing, email, and electronic database resources.
  • Ability to multi-task projects and issues on fixed timelines.

Application Instructions

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