Director, Grievance and Appeals(Preferred Experience In Managed Care)

Job Summary:

The Director, Grievance and Appeals is responsible for oversight of appeals and grievance processes.  Directing and ensuring the efficient operational management of appeals and grievance department/ function with emphasis on execution, outcomes, continual improvement and performance enhancement.

Essential Functions:

Responsible for oversight of appeals and grievance processes.  Directs and ensures the efficient operational management of appeals and grievance department/ function with emphasis on execution, outcomes, continual improvement and performance enhancement

• Designs and implements processes, policies, trainings and procedures to ensure compliance with new and existing regulations
• Addresses areas of below-standard performance and implements mechanisms to bring performance up to standard
• Tracks and trends preventable appeals and grievances and presents findings to Operations leadership
• Minimizes legal and financial risk by taking appropriate measures to protect the interest of members and providers
• Identifies need for in-house legal involvement on sensitive cases, and coordinates with plan attorneys on litigated cases, helping to oversee case preparation and research
• Provides fiscal management and support including developing operation budgets and completing forecasts and variance reporting
• Ensures appropriate systems and technology are in place to meet compliance, quality and operational efficiency measures for the department/ function
• Analyze data regularly to identify and implement process improvements
• Coordinates grievance/appeal committee meeting with appropriate parties
• Establishes and maintains cohesive relationships with internal partners
• Perform any other job duties as requested

Education and Experience:

• Bachelor of Science/Arts (BA/BS) or equivalent years of work experience is required
• Master’s degree is preferred
• Minimum of five (5) years of management experience is required
• Managed care experience is required
• Direct leadership experience in a Healthcare operational G&A environment is required
• Senior management experience is preferred

Competencies, Knowledge and Skills:

• Customer service skills with the ability to interact professionally and effectively with members, providers, internal business areas and colleagues
• Strong analytical skills with the ability to create reports and interpret operational, utilization and financial data
• Proven problem-solving skills with the ability to look for root causes and develop implementable, workable solutions
• Computer proficiency with knowledge and experience in a Windows environment
• Maintain regulatory knowledge for compliance
• Customer service orientation
• Strong written and verbal communication skills
• Ability to work in a fast paced environment
• Decision making and problem solving skills

Licensure and Certification:

None

Working Conditions:

General office environment; may be required to sit or stand for extended periods of time