Appeals and Grievances Manager

4 weeks ago

Pasadena, United States Imperial Health Plan of California, Inc. Full time

JOB SUMMARY: Oversees the department work activities assuring compliance with all regulatory guidelines and policy protocols. Serves as the team leader for the team who receives, investigates, and responds to all member grievances & appeals. Responsible for the overall compliance which include timely and accurate resolutions of grievances & appeals. Responsible for the daily management or supervision of staff performing grievance & appeals resolution. Responsible for the daily monitoring of inventory and accurate reporting. Responsible for implementing appropriate controls, development and implementation of policies and procedures, training programs and performing root cause analysis and risk assessments to maintain compliance in resolving provider disputes and provider appeals for payments

ESSENTIAL JOB FUNCTIONS:

Managing the grievance and appeals team which includes reporting, training, enforcement and auditing of internal procedures, controls, and issues.

Read, interpret, and implement all regulatory guidance related to the handling of Medicare appeals and grievances.

Demonstrate understanding of the appeals and grievance processes, including all regulatory and reporting requirements.

Establish and document processes, policies, procedures, and workflows.

Create and implement any necessary corrective action plans to bring areas of non-compliance into compliance.

Manage all grievance and appeals related reports.

Responsible for the timeliness, accuracy, and quality investigation of all cases.

Serve as the Subject Matter Expert (SME) for grievance & appeals processes and casework.

Manage direct reports to ensure cases are processed in accordance with regulatory timeframes, investigations result in Imperial Health Plan’s accurate execution of contractual benefits, and concerns are addressed to improve member experience.

Monitor audit performance, provide constructive feedback to improve quality, and train staff to proactively prevent or minimize grievance activity through solution-oriented approaches.

Ensure casework is classified appropriately in the Grievance & Appeals system (Inovaare) to support accurate data extraction of CMS, NCQA, and leadership reporting deliverables.

Assess the need for internal or external legal involvement in State Fair Hearing process, providing direction to staff for drafting Statement of Positions, and supporting hearing day as needed.




Manage staff coverage and distributes casework evenly the across team.

Draft, update, and review Grievance and Appeal Unit’s desktops, policies, and procedures to comply with relevant state and federal requirements and/or industry standards, including coordinating policies that cross Imperial departments.

Ensure proper identification and reporting of FWA, Privacy and Compliance issues discovered through the grievance & appeals process.

Work collaboratively with Medical Directors, Case Management, Claims, and operational leaders to assure compliance with company-wide policy, procedures, and standards.

Lead and/or participate in workgroups to address Grievance and Appeals issues, engaging key stakeholders, and improving systems.

Implements all changes affecting the production team in order to comply with regulatory mandates, new programs, and enhancements as defined by CMS, The National Committee for Quality Assurance (NCQA) or other applicable regulatory entity.

Develops department metrics and performance standards; assists team in meeting or exceeding departmental performance standards.

Maintains regular and consistent attendance.

Adheres to Compliance Plan and HIPAA regulations.

MARGINAL JOB FUNCTIONS:

Takes on special projects as needed.


Performs other duties as assigned.

BEHAVIORAL EXPECTATIONS:

1. Continuous Learning:

a. Attends staff meetings as required.

b. Attends appropriate training, seminars and workshops as required

2. Customer Focus:

a. Maintains client/customer confidentiality and privacy in accordance with HIPPA regulations

and IMAS’s Standards of Conduct.

b. Fosters appropriate communication and relations with Supervisor, co-workers and other staff.

3. Quality/Process Improvement/Safety

a. Reports issues of security, health and/or safety to appropriate supervisor as soon as practicable.

b. Supports and demonstrates safety throughout all duties performed.

c. Follows established policies and procedures and understands and complies with all regulators

standards set forth by governing entities.



POSITION REQUIREMENTS:

EDUCATION/EXPERIENCE:

Associate or Bachelor degree

5+ years experience working in appeals (including medical and pharmacy), or a closely related area of health plan operations

5+ years experience in investigating grievances

3+ years experience managing a A&G department in a health plan


SKILLS/KNOWLEDGE/ABILITY:

Knowledge of Medicare regulations

Extensive knowledge of Medicare Managed Care organization determination, appeals and grievance requirements, specifically reconsideration and IRE submission requirements

Strong knowledge of professional and institutional claims

Knowledge of claims & pre-service authorization processing systems (EZCAP preferred)

Ability to provide reporting requirements based on processes and/or regulatory requirements

Knowledge of medical terminology

Willingness and ability to read, write, speak, understand English and have the communications skills necessary to provide accurate information to members and staff.

Willingness and ability to follow written and verbal direction in English.

Willingness and ability to maintain appropriate level of confidentiality and privacy.

Willingness and ability to interact professionally with all customers, members, and co-workers, individually and as part of a team.

Willingness and ability to effectively handle multiple items/tasks as required and adapt favorably to changing priorities.

Willingness and ability to make appropriate judgments, decisions and problem solving in a timely manner and within the context of the situation at hand.

Ability to effectively prioritize items/tasks as required.

Willingness and ability to take initiative and be a self-starter.

Willingness and ability to understand and comply with Federal, State, and local regulations.

LICENSURE/CERTIFICATE/TRAINING:

n/a

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