Manager, Appeals & Grievances Resolutions - Medicare Advantage


Newark, NJ

Industry: Managed Care & Health Insurance


5 - 7 years

Posted 274 days ago

This job is no longer available.

Job Summary:

The Manager of GP Appeals & Grievances Resolution, Medicare Advantage (MA) is responsible for the oversight of a team dedicated to Operational Compliance for Appeals and Grievances in accordance of all CMS Regulations and Chapter 13 for Government Programs division. Manager is responsible for ensuring mandated and internal goals for timeliness, quality and production are achieved.


  • Responsible for ensuring all requirements are met regarding timeliness and resolution of complaints as mandated by CMS and regulated agencies. In addition, create and evaluate workflows/policies according to guidance and any relevant updates.
  • Allocate work assignments to ensure daily receipts are processed in accordance with Service Level Agreements (SLAs) based on order of receipt. Review work load to identify gaps in processes and/or inefficiencies.
  • Participate in all annual implementation projects related to Medicare Advantage- (EOCs, DSNP Implementation, MA implementation, Yearly Quality of ID cards). Participate in 3rd Level Administrative Law Judge Hearings. Lead in all external and internal departmental audits.
  • Identify opportunities for best practices and implement process improvements (i.e., root cause analysis, technological assessments, etc.) to optimize performance and administrative cost. These improvements can be internal or cross-functional throughout the organization.
  • Responsible for establishing, interpreting and implementing new and existing company policies and procedures based on regulations.
  • Represents the Plan with external customers, providers and external agencies and represents the unit on corporate issues.
  • Develop/updateinternal Medicare Operations training material relative to Complaint/Appeal handling.
  • Manage, develop and train staff; develop and monitor goals; conduct annual performance reviews, and administers salaries for the staff.
  • Knowledge:

  • Proficient in Medicare operations.
  • Knowledge of Federal Mandates, regulations (CTM, IRE-Maximus).
  • Knowledge of healthcare or insurance policy and/or operations preferred.
  • Requires knowledge of CMS regulations as they relate to member appeals.
  • Skills and Abilities:

  • Strong leadership, decision-making, strategic problem solving, and interpersonal skills.
  • Strong and effective communication skills, both verbal and written.
  • Strong analytical skills; uses to validate plans and approaches.
  • Ability to understand and interpret CMS mandates - Chapter 2 & 13.
  • Education:

  • Requires a bachelor?s degree (or higher) from an accredited college or university in a health related field.
  • Experience:
  • Requires five (5) years?experience in Healthcare Management or related field.
  • Requires three to five (3- 5) years of supervisory/managerial experience.
  • Requires 5years? of Appeal/Grievance/CTM resolution.

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law.