Position Summary:The Manager, Appeals and Grievances is responsible for the day-to-day management and oversight of the organization's complaint and complaint appeal operations within Amida Care. Reporting to the Director, the Manager ensures that member complaints and complaint appeals are processed, investigated, documented, and resolved timely and accurately in accordance with NYS Department of Health, regulatory, and organizational requirements. The Manager monitors complaint and complaint appeal trends, identifies recurring issues and potential areas of risk, and provides data, recommendations, and operational updates to the Director and appropriate leadership. The Manager supports the implementation of process improvements, corrective actions, staff training, quality assurance activities, regulatory audits, and other departmental initiatives designed to improve compliance, operational effectiveness, and the member experience.
Responsibilities:- Handle, investigate, and resolve all complaints received from members, providers, state and federal regulators, and other sources, ensuring appropriate follow-up, documentation, escalation, and timely resolution in accordance with federal and state regulatory requirements.
- Manage the daily activities of the Appeals and Grievances Associate, ensuring all complaints are accurately received, categorized, investigated, documented, and resolved within applicable regulatory and organizational timeframes.
- Work across Amida Care and delegated entities to ensure all complaints and inquiries are handled though appropriate escalation processes in order to meet both compliance and member needs.
- Serve as the A&G trainer for all departments regarding complaint identification, management, and complaint documentation.
- Monitor complaint trends, identifying recurring issues, provider concerns, operational deficiencies, and barriers affecting the member experience for reporting and to present in organizational meetings.
- Conduct root-cause analysis and develop recommendations to address recurring complaints and reduce preventable complaints and complaints appeals.
- Responsible for conducting Quality Assurance (QA) reviews for the complaint process to ensure accurate documentation and timeliness.
- Create data reports for management for complaints and complaints appeal as needed.
- Participate in Call Calibrations for Delegated Entities scheduled by the Quality Team for the Member Service Department.
- As requested, attend meetings to represent the Appeals and Grievances department.
- Work with Director on special projects for process improvement for the Member Experience, Member Services, A&G and Growth departments as requested.
EDUCATION REQUIRED- Bachelor's degree in health administration, Business or an equivalent combination of education and directly related work experience is required.
EXPERIENCES AND/OR SKILLS REQUIRED- Minimum four (4) years of complaints and grievances experience in a Medicaid environment.
- Significant experience with A&G tracking software required.
- Ability to collect and analyze complaint data from various data sources.
- Intermediate level of proficiency with Microsoft Word and Excel.
- Must be able to work independently and with all levels of management staff under time pressure.
- Salesforce experience preferred.
- Extensive knowledge of Medicaid regulations is preferred.
- Minimum of two to three (2-3) years of supervisory or management experience preferred
- Excellent verbal, written and interpersonal skills are required; bilingual in English and Spanish preferred.
- Demonstrate understanding and sensitivity to multi-cultural values, beliefs, and attitudes of both internal and external contacts.
- Demonstrate appropriate behaviors in accordance with the organization's vision, mission, and values.
