Supervisor, Grievance and Appeals / Job Req 956599813

Hybrid: Applicants must be a California resident as of their first day of employment.

PRINCIPAL RESPONSIBILITIES:

The Supervisor, Grievance and Appeals, under the direct supervision of the Sr. Manager, Grievance and Appeals, is responsible for direct supervision and support of the team responsible for the intake, research, and resolution within the Grievance and Appeals department. This position will be accountable for leading and directing the work for the Grievance and Appeals department by monitoring the intake, research, and resolution of all types of grievances and appeals to ensure thorough investigations are completed as outlined in the AAH's policies and procedures. This position will also perform initial and ongoing training necessary skills and knowledge base and will assist the Sr. Manager of Grievance and Appeals to establish and maintain procedures to maximize both outcomes and operational efficiency.

Principle responsibilities include:

• Provides daily supervision for Grievance and Appeals Department, including coordination of backup staffing, cross-training and deployment.
• Supervise day to day operations or applications within the scope of responsibilities including distribution of workload.
• Supervise and lead the provision of timely, efficient, equitable, and effective Grievance and Appeals services
• Hold staff accountable for regulatory and departmental standards.
• Monitor daily production goals. Identify root cause for any production issues. Implement changes as necessary and monitor outcomes. Report findings/solutions to Manager timely.
• Identify and manage personnel issues in a proactive and timely manner, with appropriate follow-up to improve performance. Ensure accurate documentation of the issue, plan and oversight to ensure performance issues are resolved. Escalate ongoing/repetitive issues to Sr. Manager.
• Performs recruiting, hiring, promotion, and performance evaluation tasks and counsels non-clinical Grievance and Appeals staff.
• Orients and trains new Grievance and Appeals staff members.
• Continually trains staff members concerning grievances and appeals.
• Maintain familiarity and compliance with federal, state and local regulations as well as other regulatory requirements (e.g. NCQA standards) relative to appeal and grievance operations.
• Provides approval decisions involving grievance billing/reimbursement determinations.
• Coordinates maintenance and updates of desktop procedures and training manuals for department
• Provides support and ownership of cases identified as escalated, complex and/or multi-issue appeals and grievances on an as needed basis.
• Collaborates with internal departments to ensure timely resolution.
• Ensures efficient, compliance, and prodcutive workflows in the operational areas of Grievance and Appeals.
• Provide direction to staff for complex/sensitive member and provider inquiries, concerns, complaints, appeals, and grievances.
• Conduct routine 1:1s with direct reports.
• Builds and maintains strong working relationships with internal departments involved in appeal and grievance resolution.
• Development, maintenance and implementation of P&Ps, workflow and training.
• Prepares and participates in Health Plan Audits, provides recommendations for Corrective Action Plans from state and federal regulatory agencies.
• Review and presents reports on trends related to appeals & grievances.
• Support staff and departments with resolving appropriate procedural issues that affect maintaining effective operations.
• Support clinical workflows and practice expectations through operational planning.
• Conduct documentation audits to ensure to adherence to quality assurance standards for quality documentation.
• Participate and/or lead organization quality improvement initiatives/projects as the G&A representative as required.
• Analyze operational and production reports on a daily, monthly, and quarterly basis. Identify trends, root causes and mitigation. Review with Sr. Manager weekly.
• Assure departmental compliance with CMS, DMHC, DHCS, and NCQA, as well as all county, state, and federal regulations, and mandates.
• Interface with and advise management on opportunities to improve efficiency of the grievance and appeals process.
• Actively participate in intradepartmental management team meetings.
• Strategize with others in UM, Pharmacy, QI, and Health Education to ensure overall optimal performance of the Health Care Services departments.
• Participate in strategic and departmental goal planning with Sr Manager and execute assigned goals.
• Represent the Sr. Manager of Grievance and Appeals, as required
• Be available to work alternative work week schedules, including weekends or holidays, as assigned, to ensure compliance with regulations.
• Be available to provide on-site/ in-person support to the department, as needed.
• Complete other duties and special projects, as assigned.

ESSENTIAL FUNCTIONS OF THE JOB

• Supervise day to day operations for the Grievance and Appeals Department
• Create and refine departmental documentation, including policy and procedures, guidelines, workflows, and other relevant documentation. Responsible for the timely revisions, maintenance, and storage of such documentation.
• Participate in strategic plan development and departmental goal planning with Sr. Manager and execute assigned goals.
• Serve as Grievance and Appeals "subject matter expert".
• Analyze operational and production reports on a daily, monthly and quarterly basis.
• Ability to work in a complex team environment and to collaborate with both external and internal professionals and others.

• Ability to demonstrate skills in prioritization, problem solving, team building, collaboration, conflict resolution, decision making and time management.
• Ability to function independently and deal with multiple, simultaneous projects.
• Ability to demonstrate a commitment to quality and excellence.
• Ability to provide effective feedback.
• Strong organization, time management and project management skills and multi-tasking abilities a must.
• Knowledge of appropriate state and federal G&A and managed care regulations required.
• Hire, supervise, and train staff.
• Perform writing, administration, analysis, and report preparation.
• Problem identification and resolution.
• Participate in audit activities.
• Excellent verbal and written communication skills.
• Lead and participate in internal and external committees and meetings.
• Comply with the organization's Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.

PHYSICAL REQUIREMENTS

• Constant and close visual work at desk or computer;
• Constant sitting and working at desk;
• Constant use of keyboard and/or mouse;
• Constant use of telephone headset;
• Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person;
• Frequent lifting of folders and various objects weighing between 0 and 30 lbs;
• Frequent walking and standing; and
• Occasional driving of automobiles.

Number of Employees Supervised: 18-20

MINIMUM QUALIFICATIONS:

EDUCATION OR TRAINING EQUIVALENT TO:

• HS diploma or equivalent, required
• Associates and/or bachelor's degree, preferred.

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:

• 5+ years of experience of Managed Care experience working in grievances and appeals, required.
• One to two years demonstrated supervisory experience or team lead in grievance & appeals or equivalent health care preferred.
• Supervisory experience, preferred.

SPECIAL QUALIFICAITONS (SKILLS, ABILITIES, LICENSE):

• Excellent verbal communication skills and effective written communications skills required.
• Ability to manage and organize large volumes of data.
• Knowledge of regulatory and accreditation entities and their requirements.
• Ability to write and implement policies and procedures.
• Ability to motivate and train staff.
• Well organized and detail oriented.
• Ability to handle multiple projects and balance competing priorities and short deadlines.
• Demonstrated skills in problem resolution, independent thinker, and logical.
• Skilled proficiency in the use of computer software including Windows and current Microsoft Office suite.

SALARY RANGE: $80,040.08 - $120,060.11 Salary

The Alliance is an equal opportunity employer and makes employment decisions on the basis of qualifications and merit. We strive to have the best qualified person in every job. Our policy prohibits unlawful discrimination based on race, color, creed, gender, religion, veteran status, marital status, registered domestic partner status, age, national origin or ancestry, physical or mental disability, medical condition, genetic characteristic, sexual orientation, gender identity or expression, or any other consideration made unlawful by federal, state, or local laws. M/F/Vets/Disabled.