The Manager, Appeals and Grievances is accountable for processing and reporting all Medicare Advantage member or provider/practitioner appeals, organization determinations, complaints and grievances for multiple health plans to the highest quality possible and for ensuring that grievances and appeals are resolved timely and within all regulatory frameworks. Responsible for the day-to-day implementation of appeals, complaints and grievances policies and procedures. This position identifies trends and issues and reports on and recommends solutions. Additionally, this role ensures that all Grievance and Appeals policies and procedures are compliant with CMS requirements.
- Develops and implements effective strategies that enables the department to maintain efficient and cost-effective processes.
- Establishes operational vision and obtains approval from with senior management relative to grievances and appeals.
- Serves as content model expert and mentor to team regarding policies and procedures, regulatory and accreditation requirements comply to CMS requirements for Medicare Advantage.
- Establishes and maintains Grievance, Appeals and Organization Determination processes and systems to ensure data quality to support Advantsure's quality, production, and financial goals.
- Manages to performance measures and standards for quality service and cost effectiveness and coaches the team to take appropriate actions.
- Participation in the staff selection process using clearly defined requirements in terms of education, experience, technical and performance skills.
- Assesses developmental needs and collaborates with others to identify and implement action plans that support the development of high performing teams and individuals.
- Leads employees and other management in developing effective intercompany workflows for the Grievance and Appeals processes.
- Manages team's productivity and resources, communicates productivity expectations, and balances workload to achieve service level agreements.
- Ensures work of team meets federal and state requirements and quality measures with respect to letter content and turn around time for appeals, compliance, and grievance handling.
- Holds individuals/team accountable for results; recognize/reward as appropriate.
- Research claim processing logic to verify accuracy of claim payment, member eligibility data, billing/payment status, prior to initiation of appeal process.
- Coordinates with the Information technology department on upgrades, fixes, and changes.
- Operates a departmental audit/oversight program that focuses on continuous quality improvement.
- Establishes regular reporting to ensure senior management is aware of Grievance and Appeals trends.
- Establishes a positive working environment that promotes collaboration, transparency, and employee engagement.
- Identifies innovative methods to improve performance and provider/customer satisfaction.
- Manages department budget including staffing projections and expenditures.
- Participates in development of annual departmental budget, monitors budget, and identifies budget discrepancies. Researches cause and makes recommendations.
- Responsible for balancing workload to optimize the effectiveness of the department.
- Collaborate with the STARs oversight team to strategize and improve ratings for our Health Plans.
- Collaborate with all operational areas on trends, root cause analysis and remediation of grievance, complaints and appeals.
Directly supervises exempt and non-exempt staff in accordance with company policies and applicable Federal and State Laws. Responsibilities include, but are not limited to, effectively interviewing, hiring, terminating, and training employees; planning, assigning, and directing work; appraising performance; rewarding and counseling employees; addressing complaints and resolving problems; supporting and encouraging the engagement process.
This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required. EMPLOYMENT QUALIFICATIONS: EDUCATION:
Bachelor's degree in a related field. Relevant combination of education and experience may be considered in lieu of degree. Continuous learning, as defined by the Company's learning philosophy, is required. Certification or progress toward certification is highly preferred and encouraged. EXPERIENCE:
Ten years' experience in a health plan operation leading an appeals and grievances department. environment Demonstrated technical knowledge Working within an A&G platform, claims platform, reporting platforms and health management platforms. Five years supervisory or leadership experience required.
Experience in Grievance and Appeals or Customer Service in a managed care or insurance environment is preferred. Bilingual skills preferred. KILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:
- Ability to work with Senior Management in creating an operating plan for the Grievance and Appeals Department.
- Experience in reading or researching benefit language.
- Experience documenting workflows and reengineering efforts.
- Experience with creating capacity plans and inventory management plans.
- Experience interacting with an Independent Review Entity.
- Experience with STARS measures.
- Experience with claim processing logic, reviewing and interpreting member eligibility data and billing and payment status.
- Proven problem-solving skills and ability to translate knowledge to corporate departments.
- Knowledge of the Grievance and Appeals regulations per CMS.
- Ability to create actionable plans through use of data analysis.
- Demonstrated track record of generating results and having an impact on organizations.
- Demonstrated forward thinking in areas of technology support, process improvement, and leadership.
- Ability to establish training programs and motivate employees in a quality minded environment.
- Strong leadership skills with the ability to mentor staff and develop teams.
- Experience with participating and leading a CMS audit for the appeals and grievances department.
- Articulate and persuasive in presenting business-case for change-management.
- Must demonstrate leadership ability and team building skills to effectively supervise professional and non-professional staff and interact with all levels of management.
- Ability to work with and empower others on a collaborative basis to ensure success of unit team.
- Ability to effectively exchange information, in verbal or written form, by sharing ideas, reporting facts and other information, responding to questions, and employing active listening techniques.
- Ability to effectively present budgetary and/or cost information and respond to questions as appropriate.
- Ability to manage multiple projects and meet necessary deadlines.
Work is performed in an office setting with no unusual hazards. Occasional travel is required. May be required to lift and carry up to 35 lbs.
The qualifications listed above are intended to represent the minimum education, experience, skills, knowledge and ability levels associated with performing the duties and responsibilities contained in this job description.
We are an Equal Opportunity Employer. Diversity is valued and we will not tolerate discrimination or harassment in any form. Candidates for the position stated above are hired on an \"at will\" basis. Nothing herein is intended to create a contract.
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