This position is responsible for the leadership and performance of all Complaints, Grievances & Appeals (CG&A) positions in an assigned site and/or strategic business unit in the delivery of high quality and cost effective care and service. This position serves in a results-oriented operations role and is accountable for ensuring compliance with state and federal regulations for processing complaints, grievances and appeals, meeting time requirements, working with customers and developing processes and procedures for continuous quality improvement. This role is accountable for the consistent implementation and effective management of CG&A policies, procedures and best practices.
- Develops, implements and monitors the CG&A programs to align with clinical programs and meet contractual requirements.
- Communicates across various departments, and drives understanding of the strategic impact of the CG&A programs for the SBU and they integrate with other clinical initiatives.
- Develops and communicates CG&A team objectives. Establishes performance goals for CG&A staff and ensure continuous feedback regularly, throughout the year. Manages attrition effectively.
- Sets performance standards and puts processes in place to regularly and consistently measure qualitative performance. Puts processes in place to identify developmental needs of team members and a means of addressing those needs.
- Responsible for coordinating and delivering staff trainings, maintaining current knowledge of accreditation standards and customer contracts and promoting system efficiencies.
- Develops and manages operating budget. Participates in strategic planning and policy development as requested by leadership. Works to achieve operational metrics in order to avoid payments of performance penalties and optimize opportunities to earn incentives.
Track record of strong operations management working with clinical and customer service organizations, general management, supervisory, team building and leadership skills; strong interpersonal skills; excellent writing and communication abilities; knowledge of relevant federal and state regulations pertaining to managed care and insurance products. Working knowledge of Microsoft Office suite.
Strategic planning and management of clinical, quality and/orappeals in a managedcare environment highly desirable.
License and Certifications - Required
License and Certifications - Preferred
LCSW - Licensed Clinical SocialWorker - Care Mgmt, LPC - Licensed Professional Counselor - Care Mgmt,RN -Registered Nurse, State and/or Compact State Licensure - Care Mgmt
Other Job Requirements
Strategic planning and management of clinical, quality and/or appeals in a managed care environment highly desirable.
Clinical license preferred (i.e. RN, LCSW, or LPC)., Track record of strong operations management working with clinical and customer service organizations, general management, supervisory, team building and leadership skills.
Strong interpersonal skills.
Effective verbal and written communication skills.
Knowledge of relevant federal and state regulations pertaining to managed care and insurance products.
Working knowledge of Microsoft Office Product Suite.