Appeals & Grievances Clinical Manager (CA Licensed)

Company Description:

Clearlink Partners is an industry-leading managed care consultancy specializing in end-to-end clinical and operational management care populations, and risk-adjusted entities.

We support organizations as they navigate a dynamic healthcare ecosystem by helping them manage risk, optimize healthcare spend, improve member experience, accelerate quality outcomes, and promote health equity.

Position Responsibilities:

Specific

• Lead and manage all clinical grievance and appeal activities for plan members.
• Develop, maintain, and oversee processes and related member communications to ensure they are accurate, clear, and culturally sensitive.
• Evaluate and track procedures for identifying quality-of-care issues, collaborating closely with cross-functional teams to effectively resolve member concerns.
• Act as the primary liaison for State Fair Hearings, audits, and inquiries from DMHC, DHCS, and other oversight entities.
• Monitor systems and workflows used to identify quality-of-care issues and work with internal partners to address and resolve both member and provider grievances.
• Ensure the smooth and timely operation of the A&G Clinical Services Unit and other related operational units.
• Oversee the timely and compliant submission of appeal and grievance reports to regulatory bodies, the Regulatory Affairs and Compliance Department, the Quality Oversight Committee, and other internal stakeholders.
• Partner with cross-functional teams to ensure correct issue coding, timely resolution of cases, and appropriate referrals to community resources.
• Represent the A&G team in internal and external meetings and workgroups, serving as the main point of contact for A&G programs, particularly clinical initiatives.
• Identify and implement strategic improvements to strengthen the overall appeals and grievances process and create an efficient, high-quality clinical appeals model.
• Collaborate across departments to build a high-performing, results-oriented Appeals and Grievances team and organizational environment.

General

• Provide support for health plan market/ product level operational oversight, management and performance improvement
• Leverage industry expertise and knowledge to provide high value consulting and advisory services
• Deliver integrated solutions in support of client goals and engagements.
• Provide delivery assurance support for engagements with assigned clients
• Support engagements ensuring completion of contracted services
• Create and/ or manage to project plans
• Prepare materials for presentation to Client executives
• Facilitate and inform key decisions through the use of data and industry best practice sharing
• Deliver concise, clear interpersonal communication to both internal and external audiences
• Facilitate streamlined exchange of information with engagement manager and client organization partner(s)
• Leverage proven methodologies and best practices in support of individual account strategies/ client plans
• Establish goals and track progress to ensure achievement
• Act in interim leadership capacity to provide supervision and oversight for teams and activities in a direct supervisory model
• Identify opportunities to improve workflow, generate accurate, high-quality productivity, support organizational compliance with requirements and deliver reductions in associated costs with improvement in organizational quality performance in collaboration with Client leaders
• Develop or update policies and procedures as required to support business needs and requirements
• Identify opportunities to streamline and/ or automate workflows
• Manage and develop staff to reach established engagement goals, deliverables and KPIs
• Adapt processes, approach, plan and/ or activities in real time to ensure critical path activities are achieved
• Support account management relationships with key client decision makers
• Develop and deploy management reporting, if indicated, to support monitoring and improvement of performance, implementing plans for improvement as necessary
• Responsible for ensuring quality, maintaining appropriate resources, competency training and education of staf
• Responsible for approving and managing day to day engagement resourcing/ time and attendance as an Engagement Manage
• Oversee compliance with internal client related audits, support Client preparation for external audits and surveys

Position Qualifications:

Competencies:

• Experience managing complex work in challenging environments through the alignment of resources and prioritization of efforts to ensure on time, in scope project and/ or strategic delivery.
• Managed care industry knowledge in operations, costs, requirements, performance and outcomes
• Product/ market operational experience in Commercial, Medicare, Medicare Advantage, Medicaid or associated lines of business
• Understanding of legal and regulatory frameworks, healthcare administration models, and internal audit procedures.
• Understanding of key regulations, frameworks, accreditation and oversight bodies to ensure compliance with complex regulatory structures.
• Knowledge of project management principles, methods, and techniques
• Ability to organize, and manage multiple competing priorities
• Strong communication skills both written and oral
• High proficiency with core office software (Excel, Word, and PowerPoint). Visio skills preferred

Experience:

• Current unencumbered RN license
• 2+ years of appeals and grievance experience in managed care environment
• 2+ years progressive experience in managed care at the Manager level or equivalent level, preferably in a government payor environment
• Minimum of 5+ years of acute clinical experience
• Minimum 2 years' experience in a managed care environment across multiple lines of business (Medicare Advantage, Managed Medicaid, Dual SNP, Commercial, etc.)
• Strong knowledge of utilization management processes and industry best practice
• Indepth knowledge and experience with the application of standard medical criteria sets (MCG, InterQual, etc.)
• Detailed knowledge and demonstrated competency in all types of medical-necessity decisions, including inpatient care, sub-acute/skilled care, outpatient care, hospice care and home health care.
• HMO and risk contracting experience preferred
• In-depth knowledge of current standard of medical practices and insurance benefit structures.
• Excellent oral and written interpersonal/communication, internal/external customer-service, organizational, multitasking, and teamwork skills.
• Bachelor's Degree preferred, will accept equivalent experience in managed care environment

Physical Requirements:

• Must be able to sit in a chair for extended periods of time
• Must be able to speak so that you are able to accurately express ideas by means of the spoken word
• Must be able to hear, understand, and/or distinguish speech and/or other sounds in person, via telephone/cellular phone, and/or electronic devices
• Must have ample dexterity which allows entering of text and/or data into a computer or other electronic device by means of a keyboard and/or mouse
• Must be able to clearly use sight so that you are able to detect, determine, perceive, identify, recognize, judge, observe, inspect, estimate, and/or assess data or other information types
• Must be able to fluently communicate both verbally and in writing using the English language
• Must be able to engage in continuous social interaction, successfully manage stressful high conflict situations, and balance multiple duties, expectations and responsibilities simultaneously

Time Zone: Mountain or Pacific

Other Information:

• Expected Hours of Work: Monday - Friday 8a.m. – 5 p.m. PST; with ability to adjust to Client schedules as needed
• Travel: May be required, as needed by Client
• Direct Reports: None
• Salary Range: $100,000 - $140,000

EEO Statement:

It is Clearlink Partners' policy to provide equal employment opportunity to all employees and applicants without regard to race, sex, sexual orientation, color, creed, religion, national origin, age, disability, marital status, parental status, family medical history or genetic information, political affiliation, military service or any other non-merit-based factor in accordance with all applicable laws, directives and regulations of Federal, state and city entities. This salary range reflects the minimum and maximum target wage for new hires of this position across all US locations. Individual pay will be influenced by Experience, Education, Specialized Soft Skills, and/or Geographic location.

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