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JOB SUMMARY

The Manager of Appeals and Grievance is responsible for leading, organizing and directing the team responsible for reviewing, researching, investigating, negotiating and resolving Member and Provider complaints, appeals and grievances for all lines of business to include Medicare, Medicaid, CHIP, Commercial Products, and ASO products.

ESSENTIAL FUNCTIONS OF THE ROLE

Manages staff responsible for the resolution of member complaints, grievances and appeals for the health plan, ensuring resolutions are compliant with established policies, procedures and regulatory requirements.

Develops and evaluates direct reports and employees. Provides timely and direct feedback to staff on cases through 1:1 meetings.

Develops working relationships with internal/external business partners for problem resolution purposes.

Identifies process gaps, and leads process improvement activities for the Appeals and Grievance Department.

Oversees the preparation of narratives, graphs, flowcharts, dashboards, etc. to be used for committee presentations, audits and internal/external reports.

Prepares reports for other bodies which have oversight responsibilities including compliance, quality improvement subcommittees and such other groups which may have need for analysis from the Appeals and Grievance Department.

Manages inventory through intake and resolution timeliness to ensure all internal and external standards are met.

Serves as a subject matter expert for NCQA accreditation standards, and requirements from regulatory agencies pertaining to complaints, grievances and appeals. Actively participates in accreditation and regulatory audits.

Assures that any Corrective Action Plans identified through auditing are addressed and actions implemented.


KEY SUCCESS FACTORS

Experience working with Commercial, Medicaid and Medicare products preferred.

Experience in appeals and grievance with strong understanding of benefit operations functional areas.

Knowledge and understanding of CMS, TDI, HHSC, NCQA, and ERISA regulatory requirements.

Experience reviewing all types of medical claims.

Strong communication and presentation skills set with the ability to present data to all levels of the organization.

Working knowledge of Microsoft Office with attention to Excel and other reporting tools.

Ability to effectively learn and use software, automated systems, or other applicable technologies.


BENEFITS

Our competitive benefits package includes the following
- Immediate eligibility for health and welfare benefits
- 401(k) savings plan with dollar-for-dollar match up to 5%
- Tuition Reimbursement
- PTO accrual beginning Day 1
Note: Benefits may vary based upon position type and/or level

QUALIFICATIONS

- EDUCATION - Bachelor's or 4 years of work experience above the minimum qualification

- EXPERIENCE - 5 Years of Experience