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The Director, Grievances & Appeals manages the client medical denials experience through organization and delivery of supporting structures, allowing for effective and comprehensive analytic review in a timely manner to provide resolutions for Humana membership. The Director, Grievances & Appeals requires an in-depth understanding of how organization capabilities interrelate across the function or segment and are managed to deliver best results within detailed requirements.

The Director, Grievances & Appeals assists members and providers, via multiple channels to support final resolution within compliance timeframes and guidelines related to support and quality related goals.

The Resolution Team handles all complaints for Humana, including formal grievances, appeals, and inquiries escalated to our executives. Our mission is to resolve these complaints quickly, effectively, and with empathy. Additionally, we leverage customer complaints to continuously improve upstream processes, ultimately reducing the number of complaints received and improving our stakeholders’ experiences.

Currently undergoing a transformation in people, process, and technology, the Resolution Team aims to enhance quality, timeliness, and the overall experience for our associates, members, and providers. As the Resolution Team Operations Director, you will be accountable for the day-to-day operations and performance of various complaint types handled by the team.

Responsibilities - In this role, the Director will:

• Offer direction and leadership to various operational teams.
• Meet or exceed all operational goals, including regulatory compliance requirements.
• Promote and build an 'Audit Ready Every Day' culture.
• Simplify and improve processes across teams.
• Drive additional operational efficiencies.
• Collaborate with upstream business partners to identify opportunities and drive initiatives to reduce complaints.
• Work closely with and support other Resolution leaders to achieve overall team operational goals, including transformation strategy.
• Increase Stars scores by improving timeliness and decision-making.
• Lead by example to cultivate a climate of motivation, positive energy, and meaningful work.
• Assess, select, recognize, develop, and empower diverse talent.
• Guide and energize others, model adaptability, and inspire strong organizational performance during periods of transformation, ambiguity, and complexity.
• Ensure all grievance and appeal processes comply with federal and state laws, including CMS guidelines.
• Implement quality control measures to monitor the accuracy and timeliness of case handling by the team.
• Prepare for CMS program audits and maintain audit readiness.
• Develop and implement policies and procedures related to grievances and appeals.
• Recommend and implement process improvements to enhance member and provider satisfaction.
• Track key metrics related to grievance and appeals volume, trends, and resolution times.
• Generate reports for leadership to identify areas for improvement.

Use your skills to make an impact
 

Required Qualifications

• Undergraduate degree
• Minimum 7 years of extensive experience in leading large-scale, highly complex operations with proven results.
• Minimum 5 years of strong leadership experience managing teams, motivating staff, and fostering collaboration.
• Minimum 5 years of strong healthcare business acumen and comprehensive understanding of Medicare and/or State regulations.
• Proven ability to drive accountability and engagement at all organizational levels.
• Familiarity with relevant laws and regulations governing grievances and appeals, including CMS guidelines
• High emotional intelligence and excellent interpersonal, organizational, communication, and presentation skills.
• Strong analytical skills with the ability to analyze complex data, identify trends, and make sound decisions.
• Problem-solving skills to effectively address complex issues and resolve grievances and appeals.
• Financial savviness with the ability to manage staffing models and a multi-million-dollar budget.
• Operational mindset with experience leading processes and implementation.

Work-At-Home Requirements

• At minimum, a download speed of 25 mbps and an upload speed of 10 mbps is recommended; wireless, wired cable or DSL connection is suggested
• Satellite, cellular and