Complaints and Grievances Specialist

Investigate member complaints, process grievances, prepare for and participate in fair hearings, and review quality concerns to determine appropriate follow-up. Ensure compliance with Pennsylvania mandates and collaborate with teams to support accountable behavioral health care. Travel is required, and the successful candidate must reside in Philadelphia or relocate there within six months of hire.

Responsibilities

• Review, document, and process complaints and grievances at all levels.
• Investigate member complaints and determine appropriate resolution or follow-up.
• Prepare hearing packets and participate in fair hearings.
• Review quality concerns arising from complaints and grievances.
• Determine whether quality concerns require investigation or tracking.
• Ensure complaint and grievance procedures follow applicable state mandates.

Required Skills

• Microsoft Office applications
• Complaint investigation
• Grievance processing
• Fair hearing preparation
• Quality concern review
• Pennsylvania Act 146
• Appendix HMedical necessity criteria
• DBH and DHS systems and services
• Training and facilitation