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Supervisor of Grievance & Appeals, Fairfield, CA


Organization: Partnership HealthPlan of California
Category: Supervisor
Location: Fairfield, CA
Date Job Posted: January 9, 2020
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Supervisor of Grievance & Appeals

Job Locations US-CA-Fairfield

Job ID 2019-1706 FLSA Status Exempt

Overview

Under direction of the Manager or above, provides supervision of the assigned Grievance staff, and assists in the day-to-day operations in the Grievance Unit by providing leadership, direction, and support to Lead Grievance Coordinators, Grievance Coordinators, and Grievance Resolution Specialists.

Responsibilities

  • Supervises staff by providing leadership, direction, and support to Lead Grievance Coordinators, Grievance Coordinators, and Grievance Resolution Specialists. Conducts regular meetings with grievance staff and provides performance feedback.
  • Manages grievance staff schedules.
  • Monitors grievance staff calls to ensure consistency.
  • Maintains an internal auditing program that identifies key improvements and measures effectiveness and compliance with regulatory requirements for all assigned staff.
  • Conducts annual performance evaluations for assigned Lead Grievance Coordinators, Grievance Coordinators, and Grievance Resolution Specialists.
  • Leads grievance training program for onboarding of new grievance staff.
  • Assists with the development of grievance staff training materials.
  • Assists with the development of training materials for internal and external stakeholders.
  • Reviews and provides guidance and interpretation to the Grievance and Appeals Resolution Manager on draft regulations and contract amendments related to Grievances.
  • Participates in workgroups and projects that involve the identification and reporting of PQI, FWA, Privacy and Compliance issues discovered through the Grievance process.
  • Participates in collecting, reviewing, and submitting materials and documents needed for internal and external audits.
  • Participates in the collection and review of data as required for internal dashboards.
  • Attends meetings on grievance system matters and prepares and distributes corresponding reports that track, trend, or analyze grievances.
  • Assists with drafting, editing, or reviewing Grievance policies and procedures to ensure compliance with relevant state and federal requirements and/or industry standards.
  • Participates in workgroups that address Grievance-system issues identified by stakeholders and through regular workflow.
  • Drafts and/or edits internal auditing tools or templates used for grievance unit activities, including but not limited to those for grievances, appeals, and hearings.
  • Conducts grievance unit internal audits to ensure quality and compliance with health plan and regulatory standards.
  • Serves as resource to Grievance Unit and PHC staff on complex grievance, appeal, and/or state hearing cases.
  • Assists with preparing cases for presentation to Grievance Review Committee, and coordinates completion of resolution actions with committee members.
  • Participates in the oversight of delegated Grievance activities, including routine auditing to ensure compliance with PHC and/or regulatory standards.
  • Maintains knowledge of current regulatory requirements under CMS and DMHC.
  • Participates in NCQA accreditation activities.
  • Periodically works with other department staff on assigned projects.
  • Serves as back up to Lead Grievance Coordinators and/or Grievance Coordinators in the event of work overflow.
  • Other duties as assigned.

Qualifications

Education and Experience

Bachelor’s degree in related field and minimum three (3) years’ experience in managed care health insurance environment. Ability to interview and investigate emotional situations with a level of sensitivity and understanding. Ability to listen effectively and appropriately respond to difficult and/or urgent situations. Demonstrate good analytical skills and the ability to problem solve creatively, objectively, and rapidly. Excellent interpersonal/verbal communication skills. Demonstrated conflict resolution and mediation skills.

Special Skills, Licenses and Certifications

Thorough working knowledge of managed care concepts, policies, and procedures. Ability to understand, interpret, and prepare documentation used in legal cases. Working knowledge of business software applications. Proficient use of computer keyboard to access data. Bilingual skills in Spanish, Tagalog, or Russian may be required. Valid California driver’s license and proof of current automobile insurance compliant with PHC 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 PHC. 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 skills, and handle sensitive issues with confidentiality, tact, and diplomacy.

Work Environment And Physical Demands

Ability to use computer keyboard. More than 60% of work time is spent in front of a computer monitor. When required, ability to move, carry, or lift objects, weighing up to 25 lbs

All HealthPlan employees are expected to:

  • Provide the highest possible level of service to clients;
  • Promote teamwork and cooperative effort among employees;
  • Maintain safe practices; and
  • Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

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 or definitive 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.

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