Manager, Grievances & Appeals

Become a part of our caring community and help us put health first
 The Manager, Grievance and Appeals ensures that products meet certain standards of quality and ensure compliance and production metrics are met. The Manager, Grievance and Appeals works within specific guidelines and procedures; applies advanced technical knowledge to solve moderately complex problems; receives assignments in the form of objectives and determines approach, resources, schedules, goals and helps to align on and drive department strategy.

The Manager, Grievance and Appeals is responsible for leading and guiding a team of leaders and associates in delivering service and operational excellence. The Manager will help to drive the investigation and resolution of member and practitioner issues. Decisions are typically related to resources, approach, and tactical operations for projects and initiatives involving own departmental area. This role requires cross departmental collaboration, and conducts briefings and area meetings; maintains frequent contact with other managers across the department.
 

• Find ways to improve the organization’s efficiency and accuracy related to Medicare Part C/D Grievance and Appeals and to minimize compliance risk exposure to the company

• Gather data from various sources and look for patterns and trends

• Perform deep-dive analyses to identify root cause failures and develop remediation action plans

• Collaborate with stakeholders including business partners, SMEs and Leadership to find process efficiencies for upstream and downstream processes and improve business performance/drive results

• Support short- and long-term operation/strategic business activities through analytics

• Interact one-on-one and consult with all levels of leadership

• Effective at working at both a data detail level and a strategic thinking level

• Analyze and interpret reports on metrics associated with goals and objectives

Use your skills to make an impact
 

Required Qualifications

• 5 or more years of equivalent work experience in Grievance and Appeals (G&A)

• 3 or more years of leadership experience 

• Strong knowledge of Medicare and Medicaid standards and regulations

• Knowledge of WorkForce Management systems and processes

• Ability to monitor and recommend improvements to improve team compliance, quality and productivity by providing expert advice and assistance to others

• Strong attention to detail, organizational and analytical skills with the ability to manage multiple priorities and/or projects

• Excellent communication and presentation skills to include the ability to communicate and present technical details to senior and/or executive level leadership

• Proficient in Microsoft Excel with the ability to perform advanced functions

• Must be able to work within Eastern Standard Time (EST) business hours

• Must be …