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Supervisor, Grievance

3 months ago

Rancho Cucamonga California, United States Inland Empire Health Plan Full time

Overview:
What you can expect

Find joy in serving others with IEHP We welcome you to join us in "healing and inspiring the human spirit" and to pivot from a "job" opportunity to an authentic experience


Under the direction of the Grievance & Appeals Manager, the Supervisor, Grievance & Appeals is responsible for ensuring that all grievance and appeal cases meet compliance standards as outlined by DMHC, DHCS, CMS, NCQA and other regulators.

The Supervisor is responsible for providing direct supervision to nurses responsible for addressing Members medical needs, under the supervision of IEHP Medical Director.

The position must maintain knowledge of IEHP regulations and NCQA standards. The Supervisor is responsible for ensuring appropriate and timely Member grievance and appeal case resolution.

Ensure that all grievance and appeal issues are addressed and resolved for the Member as soon as the medical condition requires, and within regulatory time frames.

Ensure that appropriate review of clinical issues affecting members' care. Work cooperatively with leaders from other departments that impact Member grievance and appeal case resolution.

Key Responsibilities:

  • Maintain knowledge of most current grievance and appeals regulation and NCQA standards and ensure Team Members maintain adherence.
  • Maintain knowledge of most current grievance and appeals policies and procedures, and IEHP Member benefits and eligibility, Provider Manual, IEHP Member Handbook, which is critical to the appropriate resolution of Member grievances and appeals.
  • Ensure daily staffing levels are monitored and any necessary adjustments are made to ensure timely grievance and appeal resolutions.
  • Supervise and oversee Team Members adherence to the established Grievance and Appeals Resolution System, including timelines required for Member correspondence.
  • Work closely with all Grievance and Appeals Team Members handling grievances to monitor cases received and ensure they are appropriately triaged for medical urgency and prepared and presented to Medical Director for direction.
  • Understand Member and Provider legal rights to access the Grievance and Appeals resolution process through Providers, IEHP, DHCS, DMHC, CMS, and NCQA.
  • Analyze Team Member experience and knowledge to coordinate with Learning and Development appropriate training, as necessary.
  • Review Team Member cases to understand how cases are handled. Review performance reports and as needed, coach Team Members while reviewing cases, and recommendation for additional training, as necessary.
  • Hold at least monthly one-on-one meetings with Team Members to address coaching opportunities, overall performance, quality improvement, Team Member satisfaction and feedback.
  • Prepare and participate in appeals meeting to ensure appeal cases are thoroughly reviewed.
Ensure appropriate handing of grievance and appeals acknowledgment, resolution letters:

a. Must be sent within regulatory guidelines.

b. Must show Member was made whole by addressing all issues presented and finding appropriate resolutions.

  • Assist Nurses as required to ensure proper review and processing of appeal cases.
  • As appropriate, ensure Grievance Summary Forms are sent to contracted Providers within Department timeframes. Follow-up on due dates to ensure timely grievance resolution.
  • Maintain positive working relationships with other IEHP departments to coordinate information and close grievance and appeals within regulatory timelines.
  • Ensure timely and accurate documentation of grievances and appeals. Cases must show thorough investigation and Member communication as appropriate.
  • Work closely with the Quality Assurance team to review quality assurance outcomes and implement quality assurance initiatives.
  • Assist in writing and updating grievance policies and procedures as needed. Ensure procedures comply with DMHC, DHCS, CMS. Maintain NCQA compliance.
  • Support audit-ready initiatives, regulatory and NCQA audits, including any presentation during audits and follow-up needed to ensure compliance. Participate in internal and external audits, as required.

Commitment to Quality:

The IEHP Team is committed to incorporate IEHP's Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.


Additional Benefits:
Perks


IEHP is not only committed to healing and inspiring the human spirit of our Members; we also aim to match our Team Members with the same energy by providing prime benefits and more.

CalPERS retirement

457(b) option with a contribution match

Generous paid time off- vacation, holidays, sick

State of the art fitness center on-site

Medical Insurance with Dental and Vision

Paid life insurance for employees with additional options

Short-term, and long-term disability options

Pet care insurance

Flexible Spending Account – Health Care/Childcare

Wellness programs that promote a healthy work-life balance

Career advancement opportunities and professional development

Competitive salary with annual merit increase

Team bonus opportunities

Qualifications:
Education & Experience

Three (3) or more years of working in a health care delivery setting. Previous experience in grievance and appeals resolution process. A minimum of two (2) years of prior supervisory or leadership experience.

High School Diploma or GED required.

Possession of an active, unrestricted, and unencumbered nursing license issued by the appropriate state board.

Key Qualifications

Working knowledge of grievance and appeals regulatory guidelines and NCQA standards.

Knowledge of managed care requirements, including Medi-Cal and Medicare.

Understanding of and sensitivity to multicultural community.

Ability to interpret regulatory requirements and NCQA standards and apply to grievance and appeals case resolution.


Ability to review Member grievance and appeal issues and make sound decisions that ensure all issues are appropriately addressed and Member is made whole.

Bilingual capability at translation level preferred.

Strong written and verbal communication and interpersonal skills.

Strong organization and project management skills, including oversight of timeliness and accuracy in case resolution.

Strong leadership and interpersonal skills. Familiarity with PC computers running Microsoft Windows, Microsoft Excel, and Microsoft Word; Microsoft Access experience preferred.

Ability to review and analyze department reports, including Team Member performance reports and draft remediation strategies.

Telephone courtesy and high degree of patience.

Start your journey towards a thriving future with IEHP and apply TODAY

Pay Range:
USD $ USD $66.27 /Hr.