Manager, Appeals and Grievance (47176)

WHO WE ARE:

GlobalHealth is a fast-growing Medicare Advantage HMO health insurer. We aspire to be the employer of choice in our industry, attracting and retaining a highly talented workforce. Our passion is Genuine Care and Optimal Health for the members we serve. We are unique by providing high touch, high value and a partnership to our members. We go above and beyond to provide personalized, engaging, and responsive services to our members. We work hard to offer affordable health insurance coverage with the benefits people truly want and need. It is our hope to be more than just a health insurance company we want to be long-term partners with our members. We are looking for future employees who exude our core values of taking accountability through ownership, being driven, innovative and who have a passion for continuous learning. 

WHO YOU ARE:

The successful candidate provides daily Clinical leadership and compliance of Appeals and Grievance. Identifying and executing opportunities to promote timeliness and resolution based on regulatory requirements.

ESSENTIAL JOB FUNCTIONS:

• Schedule and balance available resources to match anticipated demand
• Monitor and oversight of appeals and grievances process
• Handle escalations for member issues
• Manage employee time and attendance
• Provide coaching and training of A&G team
• Provide daily reporting for critical measures
• Identify and execute on opportunities for improvement with workflow and structure
• Manage daily workload for subordinates to ensure contractual and regulatory compliance
• Perform hiring, coaching and disciplinary actions as required
• Serve as primary Clinical representative and advocate for A&G issues and concerns in department leadership meetings
• Must maintain confidentiality of business information, including Protected Health Information (PHI), as required by HIPAA and company policy.
• Performs 1st round Quality of Care reviews
• Performs other duties as assigned

EDUCATION:                                                                                                     

• Registered Nurse (RN)
• Associate degree or bachelor’s

EXPERIENCE:

• 3 years A&G Clinical operations experience required
• 2 years appeals and grievances required
• 1 year experience with one or more of the following: MS Office (+Power BI a plus), call center management and reporting applications (Mitel) or CRM applications (Epic) required
• Familiarity with process analytics and continuous improvement methodologies (lean, six-sigma, EOS, TOC) preferred
• Proven history of successful process design and implementation preferred
• Medicare and/or NCQA experience preferred

KNOWLEDGE, SKILLS AND ABILITIES:

• Exceptional prioritization and task management skills
• Must be detail oriented and able to multitask, focusing on multiple cases at a time
• Strong documentation skills are essential
• Ability to perform essential job functions with high degree of independence, flexibility, and creative problem-solving techniques
• Ability to thrive in a resul