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Appeals and Grievances Manager
2 months ago
The Appeals and Grievances Supervisor is responsible for overseeing the Appeals and Grievances department, ensuring thorough investigations are completed according to company policies and procedures. This role involves leading and directing the team's work, monitoring research, negotiation, and resolution of all types of appeals and grievances. The supervisor provides support and takes ownership of cases identified as escalated, complex, and/or multi-issue appeals and grievances as needed.
Key Responsibilities- Lead and direct the Appeals and Grievances team
- Monitor research, negotiation, and resolution of appeals and grievances
- Provide support and take ownership of escalated, complex, and/or multi-issue appeals and grievances
- Collaborate with internal departments to ensure timely resolution
- Analyze and trend all appeals and grievances
- Develop and maintain appeal and grievance policies and procedures, workflows, member correspondence, and training
- Oversee all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports
- At least 3 years in a healthcare setting in Grievances and Appeals, Compliance, Claims or Call Center
- At least 2 years of leading process, program, or staff or supervisory experience
- Ability to manage and organize large volumes of data
- Knowledge of regulatory and accreditation entities and their requirements
- Computer ease and literacy with Microsoft Office (Word, Excel, Power Point, Access, and Visio)
- Equivalency: Completion of the L. A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement
- This position requires work after hours, on weekends, holidays, a hybrid remote schedule, occasional flexibility in hours/shift in critical situations and work on-call
- This position requires handling various caseloads and flexibility to adapt to changing priorities
