We are recruiting for a motivated Manager, Health Plan Business Operations for Grievances and Appeals - Denver Health Medical Plan (* Hybrid Work Schedule *) to join our team!

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Department

Managed Care Administration

*Hybrid Work Schedule

Job Summary

The Manager, Health Plan Business Operations for Grievances and Appeals is responsible for managing health plan operations and regulatory compliance with emphasis on grievances and appeals. Oversees review, investigation, documentation, processing, negotiating and resolving disputed medical insurance claims per federal and state regulatory requirements. Facilitates and participates in internal monitoring for compliance and regulatory audits. Provides oversight for administrative functions and management of the department, including personnel and financial management.

Committed to continuous improvement and learning. Analyzes and evaluates service for quality improvement including productivity, strategic planning, budget management, and development of performance standards. Supervises staff training and manages productivity to ensure effective and balanced case workload. Builds and manages effective partnerships that engage stakeholders in understanding the issues, identifying opportunities and assisting with resolution. Ensure that department's milestones/goals are met and adhering to approved budgets.

Essential Functions:
 

• Leads operational services of department including personnel and financial management. (30%)

• Analyzes for regulatory compliance for all lines of business. Responsible for regulatory reporting and assistance with regulatory audits. (20%)

• Establishes qualifications and performance standards for each position as well as coaches and develops staff members to ensure employee performance. (10%)

• Assesses quality of services regularly according to prescribed quality assessment methods and ensures those services are continuously improved. (10%)

• Develop Standards of Work (SOW) documentation, policies, and procedures for assigned department. (10%)

• Develops and manages Key Performance Indicators (KPIs) designed to promote optimal success and efficiency. (10%)

• Assists with developing annual operational and capital budgets and ensures that the department operates within prescribed budgetary parameters. (10%)

Education:
 

• Associate's Degree from an accredited school in business, healthcare or related field required OR

• Bachelor's degree from an accredited school in business, healthcare or related field preferred.

Work Experience:
 

• 4-6 years previous grievance and appeals experience including various lines of business including Medicare, Medicaid, CHP and Exchange preferred OR

• 4-6 years health plan operations including project and/or professional management in areas such as billing/finance regulations, planning & development, setting operational objectives, human resource management and business forecasting required AND

• 1-3 years health insurance claims processing and/or cross functional health insurance experience such as experience involving claims, enrollment, utilization management and/or finance preferred

Licenses:

Knowledge, Skills and Abilities:
 

• Health insurance claims processing knowledge - specifically QNXT experience valued

• Requires strong organizational skills to set priorities and ability to work with high degree of accuracy and attention to details while responding to tight deadlines and multiple priorities and demands.

• Able to lead, manage, advise, mentor, direct and evaluate employees with grace, fairness and accountability.

• Values and attributes that show empathy, display resilience and show sound judgement in claims management. Build and manage effective partnerships that engage stakeholders in understanding the issues, identifying innovative solutions and in supporting best practice claim management outcomes.

• Highly skilled in budget preparation/financial analysis, decision making regarding appropriateness of care review, assist with research design planning, and analyzing and generating quality improvement reports.

• Ability to work independently as well as collaboratively with