Manager, Appeals & Grievances

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Management AC 14 Penn, New York, NY, US

Salary Range: $71,325.28 To $89,161.90 Annually

Amida Care, the largest Medicaid HIV Special Needs Plan in NY, delivers a uniquely effective care model that has become a true benchmark for innovation, engagement and member health outcomes. Our mission is to provide access to comprehensive care and coordinated services that facilitate positive health outcomes and general well-being for our members. This true integrative care model addresses psychosocial, housing, behavioral and medical services directly evolving around the needs of each member.

We are a community of individuals from diverse peoples who work together to actively foster a fair, equitable, inclusive environment where all employees receive an invitation to belong. Visit http://(Use the "Apply for this Job" box below). for more information about the Amida Care culture.

We are actively seeking a highly motivated, innovative and experienced individual to join our team as the Manager, Appeals and Grievances. Compensation will be commensurate with experience.

The Manager, Appeals and Grievances is responsible for the day-to-day management and oversight of the organization's complaint and complaint appeal operations within Amida Care. Reporting to the Director, the Manager ensures that member complaints and complaint appeals are processed, investigated, documented, and resolved timely and accurately in accordance with NYS Department of Health, regulatory, and organizational requirements. The Manager monitors complaint and complaint appeal trends, identifies recurring issues and potential areas of risk, and provides data, recommendations, and operational updates to the Director and appropriate leadership.

The Manager supports the implementation of process improvements, corrective actions, staff training, quality assurance activities, regulatory audits, and other departmental initiatives designed to improve compliance, operational effectiveness, and the member experience.

• Handle, investigate, and resolve all complaints received from members, providers, state and federal regulators, and other sources, ensuring appropriate follow-up, documentation, escalation, and timely resolution in accordance with federal and state regulatory requirements.
• Manage the daily activities of the Appeals and Grievances Associate, ensuring all complaints are accurately received, categorized, investigated, documented, and resolved within applicable regulatory and organizational time frames.
• Work across Amida Care and delegated entities to ensure all complaints and inquiries are handled through appropriate escalation processes in order to meet both compliance and member needs.
• Serve as the A&G trainer for all departments regarding complaint identification, management, and complaint documentation.
• Monitor complaint trends, identifying recurring issues, provider concerns, operational deficiencies, and barriers affecting the member experience for reporting and to present in organizational meetings.
• Conduct root-cause analysis and develop recommendations to address recurring complaints and reduce preventable complaints and complaints appeals.
• Responsible for conducting Quality Assurance (QA) reviews for the complaint process to ensure accurate documentation and timeliness.
• Create data reports for management for complaints and complaints appeal as needed.
• Participate in Call Calibrations for Delegated Entities scheduled by the Quality Team for the Member Service Department.
• As requested, attend meetings to represent the Appeals and Grievances department.
• Work with…