Diana O'neil

• Ensure adherence to Fallon Health’s Standard and Expedited Appeals and Grievances processes as outlined in the Member Handbook/Evidence of Coverage, and in compliance with applicable NCQA standards, CMS, MassHealth, and other state or federal regulatory requirements.
• Participate in the validation and completion of internal dashboards and universes, ensuring accuracy and timeliness. Serve as a key contributor to data integrity analysis and remediation efforts.
• Continually develop, review, and maintain quality programs using quality improvement tools; organize and manage QA documentation and records.
• Conduct routine quality audits to assess performance and ensure regulatory and procedural compliance.
• Measure and analyze key performance indicators, compile QA reports, identify procedural gaps through quality control activities, and escalate concerns to management as appropriate.
• Assist in conducting root cause analyses to validate departmental processes and identify opportunities for improvement. Support the implementation of Corrective Action Plans, mitigation strategies, and impact assessments as needed.
• Lead and represent the UM/PA and A&G functions during external audits (CMS, NCQA, state) and internal audit activities.
• Participate in the validation and completion of internal dashboards and universes, ensuring accuracy and timeliness. Serve as a key contributor to data integrity analysis and remediation efforts.
• Recommend and participate in training initiatives based on audit findings and trends. Assist in maintaining and updating operating manuals and procedural documents to reflect regulatory or process changes.
• Support UM/PA regulatory and reporting activities as required.
• Perform additional duties as assigned to support departmental goals and respond to evolving priorities, including administrative tasks.

· Ensure adherence to Fallon Health Standard and Expedited Appeals and Grievances processes as outlined in Member Handbook/Evidence of Coverage, and in compliance with applicable NCQA standards, CMS, MassHealth and other state or federal regulatory requirements.

· Develop and review quality programs regularly. Use quality improvement tools, organize QA documents and records.

· Conduct quality audits on a regular basis. Measure and anaylizes performance metrics. Collects data and compiles QA reports. Through quality control and audits, is responsible for identifying gaps in our procedures as they relate to our internal audit practices, and escalates concerns to management. Must have the ability to analyze various situations and be able to make independent decisions on best practices in the interest of the members and the health plan to remain within compliance.

· Assists in oversight of the coordination and timely completion of member appeals including Appeal Review Committee and Letter Review examination.

· Assits with performing root cause analysis to ensure accuracy of departmental processes and identify, when needed, process improvement opportunities. Supports any necessary Corrective Action Plans, Mitigation strategies and associated impact analysis.

· Participates in Member Appeals and Grievances-related external CMS audits, NCQA Standards, state audit and/or internal audit.

· Participates in the validation and completion of internal dashboards and universes for accuracy and timeliness. Serves a primary role in data integrity reporting analysis and remediation.

Meet regularly with Department Director and management team to identify and discuss department and/or identified system issues directly effecting member and staff satisfaction to recommend plans for improvement measures and in developing and implementing specific work plans for improvements in department work processes

Works closely with department trainer to orient new staff, provides mentoring to new employees; ccommunicates expectations, assignments and responsibilities clearly and professionally; provides guidance, training, and/or assistance regarding processing of appeals and grievances; participates in employee coaching, when needed.

· Serves as primary back-up to department trainer and back-up to compliance auditor. Propose and participate in training based upon audit results and trending. Assists with operating manuals and procedural documents to ensure they stay current when regulations or processes change.

Processes a reduced caseload of member appeals and grievances, as needed. Assist with other duties, as assigned

• Processes a reduced caseload of member appeals and grievances;
• Takes on primary role or assists manager on more complex situations in researching and resolving system-wide issues, deficiencies, problems and formulates quality improvement measures;
• Participates in various meetings as a department representative; acts as a representative on various company wide projects;
• Assists department trainer to orient new staff, serving as a preceptor and provides mentoring to new employees; communicates expectations, assignments and responsibilities clearly and professionally; provides guidance, training, and/or assistance regarding processing of appeals and grievances; participates in employee coaching, when needed;
• Participates in external audit process and assists and conducts internal audits on a regular basis according to the policies and procedures as assigned by the Manager or Auditor;
• Works with manager and Medical Director to resolve member complaints; formulate improvement measures and response to member; prepare written correspondence to member;

· Meets regularly with manager and management team to identify and discuss department and/or identified system issues directly effecting member and staff satisfaction to recommend plans for improvement measures;

· Works with Manager and management team in developing and implementing specific work plans for improvements in department work processes;

· Decimates policies and procedure information to staff to ensure successful functioning of the Department

· Adheres to Fallon Health confidentiality policy; document, research and review member complaints, involving quality of care or quality of service with appropriate clinical and/or administrative staff.

Positions self as leader – models desired behavior as a professional based on organizational and cultural norms; secures team members’ “buy-in” regarding team, goals, and policies.

• Coordinated appeals processes by reviewing case files and documentation.
• Prepared written responses to customers regarding the status of their appeal or grievance filings.
• Collaborated with other departments within the organization to identify potential solutions for resolving customer disputes.
• Assessed customer complaints to determine eligibility for appeal or grievance filing.
• Provided oversight of appeals and grievances process, ensuring compliance with applicable regulations.
• Interpreted external regulations governing the handling of appeals and grievances.
• Analyzed complex cases to determine appropriate resolution in accordance with relevant laws, regulations and organizational policies.
• Organized information by using spreadsheets, databases or word processing applications.
• Retained strong medical terminology understanding in effort to better comprehend procedures.

Possess knowledge of various policy and claim systems.

• Ensures accuracy of the coverage information

• Researches ambiguous information utilizing appropriate tools and resources in

order to ensure accurate interpretation of applicable coverage.

• Correctly and accurately document information according to the established

guidelines and procedures.

• Ensure that documentation regarding various contacts and tools related to how to

obtain policy and coverage information is kept up-to-date.

• Maintain a continuous improvement outlook by sharing best practices and

maintaining an open dialogue with customers.

• Provides technical expertise and assist in development of fellow team members as

appropriate.

• Demonstrates engagement and model leadership behaviors consistent with Unum

US Leadership Expectations.

Possess an understanding and working knowledge of Unum disability products,

policies and contracts.

• Familiar with reference materials and tools regarding medical, vocational and

disability issues.

• Partners with customers in their efforts to return to work or to independent living

• Provides excellent customer service in accordance with Unum’s "Commitment of

Service" and other organizational service standards.

• Able to utilize claim investigative techniques to identify and evaluate claim

information in a fair and objective manner.

• Demonstrates ability to make balanced decisions with the highest degree of

integrity and fairness.

• Able to work with others in a highly collaborative team environment.

• Communicate effectively both verbally and in writing.

• Ability to interact effectively and professionally with claimants, employers, medical

personnel, attorneys, representatives, brokers/agents, and others.

• Development of conflict resolution and negotiating skills.

• Ability to develop a good working knowledge of claim validation, early

intervention, and return-to work techniques.

• Assisted customers with policy inquiries and claims processing.
• Resolved customer complaints through effective communication and problem-solving.
• Processed policy changes and updates accurately in the company system.
• Educated clients on insurance products and coverage options available.
• Answered customer inquiries and provided accurate information regarding products and services.
• Actively participated in team meetings to improve service standards and practices.
• Provided excellent customer service to resolve customer complaints in a timely manner.
• Remained calm and professional in stressful circumstances and effectively diffused tense situations.
• Developed strong customer relationships to encourage repeat business.
• Maintained detailed records of customer interactions, transactions and comments for future reference.
• Performed administrative tasks such as filing paperwork, updating databases and generating reports.