Bachelor's Degree or equivalent experience in Healthcare or human service-related field.
5+ years in managed health care setting, preferably Medicare/Medicaid.
Excellent presentation, group motivation, and supervisory skills.
Strong strategic planning, critical thinking, and leadership abilities.
Demonstrated management experience in a healthcare context.
Experience coordinating diverse groups to achieve program success.
Advanced proficiency in Microsoft Office Suite.
Responsibilities
Manage daily operations of the Grievance and Appeals team to meet organizational goals.
Establish effective workflows and monitoring processes for timely grievance and appeal functions.
Act as a resource for staff, assisting in problem-solving and system improvements.
Ensure compliance with regulatory standards, including CMS and DMHC, through training and monitoring.
Train staff to classify cases and prepare them for review by medical professionals.
Facilitate staff and interdisciplinary team meetings to promote teamwork.
Maintain up-to-date department policies and training materials to ensure quality care.
Benefits
Annual employee bonus program.
Robust Wellness Program.
Generous paid-time-off (PTO) and eleven paid holidays, plus additional floating and birthday holidays.
Excellent 401(k) Retirement Saving Plan with employer match.
Tuition reimbursement for professional development opportunities.
Opportunity to make a meaningful impact on members and the community.
Full Job Description
The Job
The Manager, Grievances and Appeals Operations manages daily operations within the SCAN Grievance and Appeal program to assure that appeals and grievance rights provided to SCAN members are delivered efficiently, effectively and in accordance with all regulatory requirements.
You Will
Ensure alignment to and achievement of the organizations goals by managing and overseeing the Grievance and Appeals team the day-to-day operations and productivity.
Ensure completion of required activities for grievance and appeal functions within the required timeframes by establishing and maintaining effective workflow, systems, tools and monitoring processes and by performing necessary process improvements.
Ensure staff performance by acting as the first line resource for staff and assisting in problem solving specific issues as well as improving systems and tools, implementing and maintaining proper staffing including use of temporary staff.
Ensure compliance with and adhere to all regulatory and quality standards including but not limited to: Centers for Medicare and Medicaid Services (CMS), Department of Managed Health Care (DMHC), Department of Health Care Services (DHCS), and Department of Managed Health Care (DMHC) as it relates to the Grievance and Appeal Department activities by establishing and maintaining processes for understanding, training to, and monitoring adherence to the standards and by preforming necessary process improvements to address areas of identified non-compliance.
Ensure staff is trained to review incoming inquires for both Medicare Part C and Part D, determine case classification, and prepare cases for review by either the Pharmacist or the Medical Director following SCAN and department policies and procedures to achieve organizational goals and outcomes.
Ensure environment and culture of teamwork by facilitating staff meetings and interdisciplinary team meetings.
Ensure that department policies and procedures, desktop procedures, workflows, job aides, and training materials, are current and accurately reflect processes in order to provide consistent quality care and comply with regulatory requirements.
Partner with stakeholders and department management to create and review department metric reporting for productivity and efficacy to support organizational vision and goals.
Function as the department subject matter expert and represent department at assigned committees to support two-way communication.
Interface with HCS Medical Director to ensure quality case review occurs in accordance with department policy and procedures.
Maintain staff by recruiting, selecting, orienting, and training employees; maintaining a safe and secure work environment; and developing personal growth opportunities.
We seek Rebels who are curious about AI and its power to transform how we operate and serve our members.
Actively support the achievement of SCAN's Vision and Goals.
Other duties as assigned.
Your Qualifications
Bachelor's Degree or equivalent experience in Healthcare or human service-related field of study.
5+ years in managed health care setting, Medicare/Medicaid preferred.
Excellent presentation skills, group motivation and supervisory skills.
Strong strategic planning, critical thinking and leadership skills.
Demonstrated management experience.
Experience with coordinating diverse groups of individuals to achieve success of the overall program.
Ability to prioritize multiple and competing tasks, work independently and in a team environment.
Ability to work well in a fast-paced and dynamic environment.
Strong interpersonal skills, including excellent written and verbal communication skills.
Strong organizational skills.
Ability to multitask.
Ability to appropriately maintain confidentiality.
Strong analytical and critical thinking skills, required.
Working knowledge of guidelines and regulations relevant to Grievance and Appeals including Medicare, Medi-Cal, DMHC, DHCS, and NCQA Guidelines.
Demonstrated ability to work with all levels of staff, within and external to the organization to achieve goals.
Microsoft Office Suite experience at advanced level.
What's in it for you?
Base salary range: $80,300 to $116,197 per year
Internal title
Work Mode
An annual employee bonus program
Robust Wellness Program
Generous paid-time-off (PTO)
Eleven paid holidays per year, plus 1 floating holiday, plus 1 birthday holiday
Excellent 401(k) Retirement Saving Plan with employer match and contribution
Robust employee recognition program
Tuition reimbursement
An opportunity to become part of a team that makes a difference to our members and our community every day!
We're always looking for talented people to join our team! Qualified applicants are encouraged to apply now!
