Appeals and Grievances Supervisor
12 hours ago
Job summary:
The Supervisor, Customer Solution Center Appeals & Grievances is responsible for direct supervision and support of the team responsible for the intake, research, resolution, tracking, trending and reporting within the Appeals & Grievances department.
This position will be accountable for leading and directing the work for the Appeals & Grievances department by monitoring the research, negotiation and resolution of all types of appeals and grievances to ensure thorough investigations are completed as outlined in the company policies and procedures.
Provides support and ownership of cases identified as escalated, complex and/or multi-issue appeals and grievances on an as needed basis.
Collaborates with internal departments to ensure timely resolution.
This position will be responsible for analyzing and trending for all appeals and grievances.
Responsible for the development and maintenance of the appeal and grievance Policies and Procedures, workflows, Member correspondence, and training as needed, or on an annual basis.
Duties
Evaluates daily reports to ensure individual and team Key Performance Indicators (KPIs), SLAs, Performance Scorecards meet regulatory requirements.
Provide direction to staff for complex/sensitive member and provider inquiries, concerns, complaints, appeals, and grievances.
Conduct weekly 1:1s with direct reports.
Builds and maintains strong working relationships with internal departments involved in appeal and grievance resolution.
Development, maintenance and implementation of P&Ps, workflow and training.
Audit preparation and providing recommendations for Corrective Action Plans from state regulatory agencies.
Performs other duties as assigned.
Qualifications:
Education:
Master's Degree Preferred
Experience
Required:
At least 3-5 years in a healthcare setting in Grievances and Appeals, Compliance, Claims or Call Center.
At least 2-3 years lead/supervisory experience.
Preferred:
Previous experience in Managed Health, preferably in Customer Service, Appeals and Grievances and/or Claims.
Skills
Required:
Ability to manage and organize large volumes of data.
Knowledge of regulatory and accreditation entities and their requirements.
Excellent verbal and written communication skills and interpersonal skills.
Good working knowledge of licensure and regulatory requirements, and accreditation standards.
Ability to work independently.
Ability to solve complex issues and identify creative solutions.
Computer ease and literacy with Microsoft Office (Word, Excel, Power Point, Access, and Visio).
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