Responsible for oversight of member appeals and grievance processes. Directs and ensures the efficient operational management of appeals and grievance departments/function with emphasis on execution, outcomes, continual improvement and performance enhancement.
- Directs and ensures the efficient operational management of appeals and grievance departments/function with emphasis on execution, outcomes, continual improvement and performance enhancement.
- Participates on several internal committees to engage and offer input and guidance relative to risk assessment activities, impact of regulatory changes.
- Designs and implements processes, policies, trainings and procedures to ensure compliance with new and existing regulations.
- Addresses areas of below-standard performance and implements mechanisms to resolve risk management issues.
- Tracks and trends preventable issues and grievances and leads a committee focused on organization procedural improvements.
- Minimizes legal and financial risk by taking appropriate measures to protect the interest of providers, employers and members. Determines the potential loss and financial risk of unusual occurrence cases.
- Identifies need for in-house legal involvement on sensitive cases, and coordinates with plan attorneys on litigated cases, helping to oversee case preparation and research.
- Appears in court for small claims and administrative law judge cases to ensure appropriate representation of the Health Plan.
- Provides fiscal management and support including developing operational budgets and completing forecasts and variance reporting.
- Leads development of Business Area Requirement Reports (BARR) and business cases to ensure systematic capabilities and configuration.
- Acts as the point of contact for all areas of the Health Plan providing guidance, input and interpretation of policies, and ensuring compliance with internal and external requirements.
- Performs other duties as required.
Education/Experience: Bachelor's Degree in a related field or equivalent experience. Master's Degree preferred. 5+ years of experience in grievances, appeals, or healthcare law related fields. Previous management experience in managed care operations, including managing cross functional teams on large scale projects or supervisory experience including hiring, training, assigning work and managing the performance of staff.
Job ID 1119007