Team Lead, Grievance & Appeals

Job Summary:

The Team Lead, Grievance and Appeals oversees the day-to-day performance of grievance and appeals specialists, while ensuring all regulatory, compliance and HIPAA guidelines are met for Medicaid, Medicare and the Massachusetts Market.

Essential Functions:

• Supervise staff for quality review, performance feedback, disciplinary issues and merit/bonus appraisal review
• Meet all monthly, annual and semi-annual reporting deadlines
• Work with Regulatory Compliance Officers to ensure that requests are resolved within time lines and tracked for reporting
• Monitor Medicaid and Medicare processes to ensure that all regulatory requirements are followed
• Work with support departments and compliance officers to ensure policies and procedures are current
• Establish an audit process
• Responsible for evaluating operations and identifying process improvement needs.  Identify irregular trends with grievances and appeals; work with other areas as appropriate to identify root causes and appropriate steps for resolution
• Responsible for staffing, ensure that open positions are filled, and evaluate future staffing needs
• Review validation reports to ensure that grievances and appeals are accurate
• Develop and monitor workflows for Grievance and Appeals Department that ensures maximum level of productivity
• Monitor member-facing departments to ensure that grievances and appeals are resolved and reported to the Grievance and Appeals Department
• Conduct audits and provide feedback to all areas that submit grievances and appeals
• Facilitate timely resolution of member and provider issues.
• Ensure that Grievance and Appeals Specialists are available to respond to incoming calls
• Coordinate incoming information and disseminate to staff to ensure accuracy of communication to internal and external customers.
• Create, review, revise and enforce company and departmental policies and procedures
• Act as the contact point for CareSource on operational issues to all regulatory bodies in existing and future lines of business
• Actively interact with IT department for immediate problem resolution and for coordination of data transmissions
• Proactively keep the management team apprised of the team’s performance, projects and issues
• Provide support to the Service Center during high call volume or other support as needed
• Develop, deliver or coordinate the delivery of grievance and appeals training to other areas as needed.
• Perform any other job related instructions, as requested

Education and Experience:

• Associates Degree or equivalent years of relevant work experience required
• Minimum of three (3) years of customer service experience in an HMO or related industry
• Previous supervisory/leadership experience preferred

Competencies, Knowledge and Skills:

• Basic computer skills including Microsoft Word, Excel and PowerPoint
• Basic experience with ACD systems
• Basic experience with Call Management Systems
• Communication skills
• Prior supervisory skills
• Ability to work independently and within a team environment
• Attention to detail
• Familiarity of the healthcare field and knowledge of Medicaid
• Critical listening and thinking skills
• Training/teaching skills
• Strategic management skills
• Negotiation skills/experience
• Proper grammar usage
• Technical writing skills
• Time management skills
• Proper phone etiquette
• Customer service oriented
• Decision making/problem solving skills
• Strong language skills
• Ability to write comprehensive statements using proper grammar and sentence structure

Licensure and Certification:

• None

Working Conditions:

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

Compensation Range:

$62,700.00 - $100,400.00

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Salary

Organization Level Competencies

• Fostering a Collaborative Workplace Culture

• Cultivate Partnerships

• Develop Se