Manager of Grievance and Appeals

US-RI-Smithfield
Req No.
2017-8055
Department
Grievance and Appeals
Type
Regular Full-Time
Category
Grievance And Appeals

Overview

This position oversees the process of advocating for member rights within the organization, assuring grievance and appeal trends are reported to and addressed within the appropriate quality improvement committee(s). Provides supervision to the Grievance and Appeals (GAU) department and oversees the organization of work and work-flow so that performance standards and procedures for appeals resolution are consistent with client, state and federal requirements. He/she is responsible for the oversight of the grievance and appeals process across the company for providers and members as well as oversees the member complaint process. This position ensures all processes meet contractual and regulatory requirements across all lines of business. He/she is responsible for gathering and analyzing data related to the performance of the department and company and identifying process improvement opportunities. He/she is also responsible for monthly, quarterly and annual reporting as required by regulatory bodies.  

Responsibilities

  • Engage in on-going performance management of staff including coaching, mentoring, development, training and succession planning to include hiring and termination decisions.
  • Serves as the subject matter expert and lead on functional deliverables ensuring optimal efficiency in area of responsibility.
  • Manage to ensure operational excellence.
  • Oversee daily operations related to grievance and appeals and member complaints to ensure department service key performance measures and external regulatory requirements are achieved
  • Monitor and manage processes related to grievance and appeals to ensure compliance across the company and within the GAU.
  • Reviews case against clinical records, clinical guidelines, policies, EOC/COI/Benefit Agreement, Benefit Policy and coding guidelines.
  • Reviews, triages and prioritizes cases to be handled within established timeframes and tracked for reporting.
  • Expedites referrals to appropriate area or delegated entity to ensure access to appropriate care for members with current care needs and/or resolves appeal/grievances using expedited process
  • Presents cases to Medical Director and/or supervisor for review or determinations.
  • Interacts with the member, provider and/or GAU staff to ensure resolution of plan recommendations. 
  • Compile all required internal and external reports; meet all monthly, annual and semi-annual reporting deadlines.
  • Monitor Medicaid and Medicare processes to ensure that all regulatory requirements are followed.
  • Continually evaluate operations and identifying process improvement needs.  Identify irregular trends with grievances and appeals and member complaints; work with other areas as appropriate to identify root causes and appropriate steps for resolution.
  • Develop and monitor workflows for the GAU that ensures maximum level of efficiency.
  • Monitor and work with member-facing departments to ensure that grievances and appeals and member complaints are resolved and reported to the GAU
  • Ensure that GAU Specialists are available to respond to incoming calls during specified hours of operation.
  • Proactively keep the management team apprised of the team’s performance, projects and issues.
  • Develop, deliver and/or coordinate the grievance and appeals training to other areas as needed. 
  • Attend meetings/serve as committee member as required.
  • Ensure all staff adheres to regulations, audits, compliance and privacy guidelines.
  • Other duties as assigned.
  • Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood’s Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and  the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents.

Qualifications

Required:

  • Bachelor’s Degree
  • Three (3) to Five (5) years workings of health plan grievance and appeals, specifically Medicare and Medicaid regulations
  • Three (3) to (5) years of experience with leadership and supervisory experience
  • Strong Customer Service orientation
  • Experience communicating with providers and members
  • Demonstrated experience in data collection, presentation and action plans
  • Demonstrated ability to effectively prioritize and execute tasks and special projects
  • Intermediate to Advanced skills in Microsoft Office (Word, Excel, PowerPoint, Outlook)
  • Strong verbal written communications skills
  • Ability to work both independently and as a team member
  • Ability to influence without authority

Preferred:

  • Registered Nurse
  • Related Professional Training and/or Certifications
  • Experience in Behavioral Health

Neighborhood is an Affirmative Action and Equal Opportunity Employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, national origin, genetic information, age, disability, veteran status or any other legally protected basis.

 

Neighborhood is committed to ensuring individuals with disabilities and/or those who have special needs participate in the workforce and are afforded equal opportunity to apply for jobs. If you would like to contact us regarding the accessibility of our Website or need assistance completing the application process, please contact us at recruiting@nhpri.org

 

Neighborhood is an EOE M/F/D/V and an E-Verify Employer

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