GRIEVANCE & APPEALS SUPERVISOR
The Health Plan of San Mateo (HPSM), a managed care health plan, seeks a full time Grievance & Appeals Supervisor. Working in collaboration with other departments, oversee member complaints for all lines of business in a manner consistent with regulatory requirements and plan policies and procedures. Act as primary resource for G&A Coordinators for case resolution and provide feedback to G&A Coordinators regarding casework.
The essential duties and responsibilities will include the following:
- Plan, prioritize and assign tasks to Grievance and Appeals staff. Ensure that cases are handled based on priority and are routed to the appropriate functional area required to resolve the case.
- Accomplish staff results by communicating job expectations; planning, monitoring, and appraising job results; coaching, counseling, and implementing corrective action steps when necessary; developing, coordinating, and enforcing systems, policies, procedures, and productivity standards. Complete performance evaluations in a timely manner.
- Conduct quality review of case files to ensure all issues and required actions within a case are completed and appropriately categorized in accordance with state and federal regulations.
- Maintain accurate and complete appeals/grievance records in the database.
- Ensure appropriate grievance acknowledgement, resolution, and appeal letters are sent out within regulatory compliance guidelines.
- Review all systems throughout the day to ensure all cases are captured and assigned appropriately. Systems include: cases received by the Member Services/CareAdvantage Units and forwarded by other HPSM Departments, received online, via mail, in person, via facsimile and Medicare Complaint Tracking Module (CTM).
- Keep Grievance and Appeals Manager and HPSM leadership aware of “open” and “pending” grievance/appeal issues and expected resolution measures.
- Review requests for State Fair Hearing Statements of Position, Maximus and Independent Medical Review (IMR) packets to ensure cases are documented properly, investigations are complete, all issues are addressed; and appropriate decision-making criteria, regulations and standards are applied.
- Handle escalated member or provider cases/calls as needed. Effectively communicate with members and providers verbally and in writing.
- Schedule regular department meetings to review grievance and appeals cases, and facilitate regular department communication.
- Collaborate with the Grievance and Appeals Manager in training efforts internally and externally, including the development of training materials. Conduct new hire training and coordinate opportunities to shadow and observe in accordance with training guidelines and protocols. Observe new hires and provide feedback to the staff. Communicate feedback to Grievance and Appeals Manager.
- Attend and present cases at bi-weekly Staff Grievance and Appeals Committee.
- Review work procedures and recommend or change procedures to be more time/cost efficient.
- Conduct regular audits of Grievance and Appeals Coordinators’ work, analyze results, coordinate the collection of deliverables, and execute corrective action plans (CAP) to address any identified issues.
- As needed create and analyze internal and regulatory reports of the Grievance and Appeals Unit performance and trends.
- Participate in audits and prepare responses to audit findings and/or corrective action as needed.
- Assist with special projects.
- Perform other duties as assigned.
Education and Experience:
- Bachelor’s degree and/or Master’s degree in related health care field preferred (Public Health, Heath Care Administration, Business, Social Services, Humanities and Policy).
- Equivalent to two (2) years’ experience working with Medi-Cal or Medicare in a managed care environment. Education may be substituted for experience.
- Work in a call center, claims department, and/or other customer service position preferred.
- Previous experience working in a lead or supervisory capacity preferred.
- Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, Access and PowerPoint.
- Medicare, Medi-Cal, Managed Care and medical terminology
- State and federal regulation pertaining to the processing of grievances and appeals
- Supervisory principles and practices as well as techniques and methods
- Work cooperatively with others
- Work as part of a team and support team decisions
- Communicate effectively, both verbally and in writing
- Adapt to changes in requirements/priorities for daily and specialized tasks
- Communicate effectively, both in writing and orally, as well as possess a high level of attention to detail
- Make presentations to internal and external audiences and represent the HPSM in a positive manner
- Communicate and present complex data and concepts in a manner that is easily understandable to a wide range of audiences
- Interpret state and federal regulations, laws, and contractual obligations and translate them into policies, procedures, standards and guidelines
- Plan, assign, supervise and evaluate the work of others and monitor goals, objectives, deadlines and priorities
- Summarize, draw conclusions from, and communicate data and trends for planning and compliance purposes
Compensation and Benefits
Starting Compensation Range: - Depending on Experience
Benefits Information: Excellent benefits package offered, including HPSM paid premiums for employee’s Medical, Dental and Vision coverage. Employee pays a small portion of the dependent premiums (5%) for medical and dental benefits. Additional HPSM benefits include fully paid life, AD&D, and LTD insurance; retirement plan (HPSM contributes equivalent of 10% of annual compensation); holiday and vacation pay; tuition reimbursement plan; onsite fitness center and more.
How to Apply
Application Process: To apply, submit a resume and cover letter with salary expectations to: Health Plan of San Mateo, Human Resources Department, 801 Gateway Blvd., Suite 100, South San Francisco, CA 94080 or via email: email@example.com or via fax: (650) 616-8039. File by: Continuous until filled. The Health Plan of San Mateo is proud to be an Equal Opportunity Employer and encourages minority candidates of all backgrounds to apply.
Submissions without a Cover Letter and Salary Expectations may not be considered.