Manager,Grievance & Appeals Job San Jose area,California USA,Management

Manager, Grievance & Appeals

Salary Range: $133,757 - $207,324 The expected pay range is based on many factors, such as experience, education, and the market. The range is subject to change.

FLSA Status: Exempt Department: Grievance & Appeals Reports To: Director, Operations

GENERAL DESCRIPTION OF POSITION

The Manager, Grievance & Appeals is the primary point person responsible for the development and management of all grievance and appeal related activities and for providing a positive and professional experience for members and providers going through grievance or appeals processes. As the go-to person for grievances and appeals, this position interprets guidance from regulators, implements processes to ensure compliance, oversees the day-to-day operations of the grievance and appeals staff and represents the plan externally with providers, delegates and regulators in scheduled and ad hoc meetings, joint operating committee meetings, hearings and audits.

ESSENTIAL DUTIES AND RESPONSIBILITIES

To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below.

Read, interpret and implement all regulatory guidance related to the handling of appeals and grievances, including the Medicare Managed Care Manual, State and Federal contracts , APLs,DPLs and other memos that provide direction.

Demonstrate a solid understanding of the appeals and grievance processes, including all regulatory and reporting requirements.

Establish and document processes, policies, procedures and workflows to support compliant and timely handling of appeals and grievances.

Create and implement any necessary corrective action plans to bring areas of non-compliance into compliance.

Manage all grievance and appeals related reports ensuring accuracy and timeliness of submissions.

Prepare case files and represent SCFHP in State Hearings or other escalated types of cases, including development of the Statement of Position and Independent Review Entity (IRE) case narratives.

Act as the subject matter expert and initial point of contact for complex and escalated grievance and appeals cases for the department staff.

Schedule regular department and cross functional meetings with contributing departments to review grievance and appeal cases and facilitate regular communications.

Lead and facilitate active participation and guidance from the attendees of the Grievance and Appeals Workgroup.

Lead efforts to identify grievance and appeal case trends and conduct root cause analysis for the development of interventions to improve SCFHP operations and the customer experience for members and providers.

Manage internal and external audits of grievance and appeals.

Demonstrate competency to utilize existing systems and represent the appeals and grievance team in establishing or implementing new systems related to appeals and grievances.

Develop, document, and train staff on appeals and grievance categorization, systems, processes, policies, procedures, and workflows required to manage the appeals and grievance processes throughout the organization.

Direct and manage appeals and grievance staff in order to adhere to accurate processing and resolution of appeals and grievances. This includes demonstrating the flexibility and judgment required to constantly re-shift prioritization of cases to accommodate timely handling and resolution.

Develop and manage reporting to monitor key performance indicators, identify trends, conduct root cause analysis, report to appropriate committees, and adhere to regulatory reporting requirements.

Communicate effectively both internally and externally in order to continuously improve communication and quality. Work cross functionally, including attendance at organizational and departmental meetings to train and address issues that may prevent the appropriate identification of and resolution of appeals or grievances.

Perform other related duties as required or assigned.

SUPERVISORY/MANAGEMENT RESPONSIBILITIES

Carries out supervisory responsibilities in accordance with the organization's policies, procedures, applicable regulations and laws.

Responsibilities include:

Managing the grievance and appeals team with regard to work priorities, projects, reports, and maintenance of the G & A system(s), including training, promotion, enforcement and auditing of internal procedures, controls and problems; motivating employees to achieve peak productivity, performance and quality. Monitoring work schedules and time off…