Manager of Grievance and Appeals, Fairfield, CA
Manager of Grievance and Appeals
Job Locations US-CA-Fairfield
Job ID 2018-1373
The Manager of Grievance & Appeals serves as the team leader for the production team who receives, investigates, and responds to all member grievances, appeals, state hearings, and expedited cases. Manages day-to-day activities, clinical solutions, and is responsible for the timeliness, accuracy and quality investigation of all cases. Will manage the production team consisting of Grievance Clinical Nurses, Supervisors of Grievance Coordinators, and Grievance Resolution Specialists. Activity engaged in casework, monitors reoccurring issues, explores root causes, and presents monthly trends to the Associate Director of Grievance & Appeals.
Serves as a motivational leader, supports professional development of team, implements operational efficiencies, and considers new clinical approaches that minimizes Partnership HealthPlan’s risk. Promotes a positive member experience, acts as an innovative problem solver, and helps the team arrive at long-term solutions for their casework. Embraces accountability, strong work ethics and integrity. May represent the Grievance & Appeals Department while serving on and/or presenting at internal and external committees.
Provides strategic leadership, training, and direction to grievance staff by:
- Serving as the Subject Matter Expert (SME) for grievance processes and casework.
- Managing direct reports to ensure cases are processed in accordance with regulatory time frames, investigations result in Partnership HealthPlan’s accurate execution of contractual benefits, and concerns are addressed to improve member experience.
- Monitoring audit performance, providing constructive feedback to improve quality, and training staff to proactively prevent or minimize grievance activity through solution-oriented approaches.
- Ensuring casework is classified appropriately in the Grievance & Appeals system (Everest) to support accurate data extraction of DHCS, NCQA, and leadership reporting deliverables.
- Assessing the need for internal or external legal involvement in State Fair Hearing process, providing direction to staff for drafting Statement of Positions, and supporting hearing day as needed.
- Managing staff coverage and distributes casework evenly the across team.
- Endorses, promotes, and ensures sustainability of the SME Ambassador program.
- Drafting, updating, and reviewing Grievance and Appeal Unit’s desktops, policies, and procedures to comply with relevant state and federal requirements and/or industry standards, including coordinating policies that cross PHC
- Ensuring proper identification and reporting of PQI, FWA, Privacy and Compliance issues discovered through the grievance
- Working collaboratively with Medical Directors, Case Management, and operational leaders to assure compliance with company-wide policy, procedures, and standards.
- Leading and/or participating in workgroups to address Grievance and Appeals issues, engaging key stakeholders, and improving
- Co-chair the Member Grievance Review Committee with the Medical Director. Presents statistics, trends, key case summary reviews, and recommends new initiatives to improve member experience.
- Implements all changes affecting the production team in order to comply with regulatory mandates, new programs, and enhancements as defined The National Committee for Quality Assurance (NCQA), DHCS, or other applicable regulatory entity.
- Working with Associate Director to identify and establish priorities, metrics, and enhancements to advance Partnership HealthPlan.
- Oversee the development and implementation of a robust training program for new hires.
- Monitor team performance and production through reports, auditing results, and provides coaching as needed.
- Interviews, hires, promotes, terminates, coaches, and trains staff
- Conducts monthly staff meeting and supports staff meetings of direct reports.
- May lead other initiatives or attend other committees as assigned by Associate Director of Grievance & Appeals.
Education and Experience
Bachelor’s degree in Business, Nursing, Healthcare Management, or other related field required. Master’s degree or Registered Nurse licensure preferred. At least 3 years’ experience in management. Experience in grievance and appeals, case management, customer service, account management, or serving disgruntled customers strongly preferred. Will manage onsite and telecommuting staff. Excellent written and interpersonal communication skills. Experience presenting presentations. Demonstrated conflict resolution and mediation skills. Confident, autonomous, solution driven, proactive, detail oriented, high standards of excellence, nonjudgmental, diplomatic, resourceful, intuitive, dedicated, and resilient.
Special Skills, Licenses and Certifications
Thorough working knowledge of managed care concepts, policies, and procedures. Ability to understand, interpret, and prepare documentation used in State Hearing cases.
Prefer valid Registered Nurse licensure. Valid California driver’s license and proof of current automobile insurance compliant with Partnership HealthPlan policy are required to operate a vehicle and travel for company business.
Performance Based Competencies
Ability to learn quickly and acquire in-depth knowledge of software used at Partnership HealthPlan. Excellent analytical skills to troubleshoot and resolve system problems. Able to develop procedures and document extensively and clearly. Excellent oral and written communication skills. Excellent analytical and interpersonal skills. Ability to assess and resolve customer complaints, problems, and issues in an effective manner. Excellent organizational skills. Ability to prioritize issues, use good judgment, and handle sensitive issues with confidentiality, tact, and diplomacy.
Work Environment And Physical Demands
Ability to use a computer keyboard. More than 60% of work time is spent at a computer monitor. May travel up to 25%.
All HealthPlan employees are expected to:
- Provide the highest possible level of service to clients
- Promote teamwork and cooperative effort among employees
- Practice Partnership HealthPlan’s culture
- Abide by Partnership HealthPlan’s policies and procedures
IMPORTANT DISCLAIMER NOTICE
The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.