Our client provides a range of health solutions for rural communities. With new projects on the horizon, they are hiring an Appeals and Grievances Manager to oversee the appeals and grievances process and ensure both are processed in accordance with regulations and industry standards.
The Appeals and Grievances Manager will act as a liaison between members and providers regarding grievances, complaints, and appeals related to denials of medical services, benefits issues, reimbursements, and quality of service. They will be responsible for conducting thorough research, detailed documentation, and corrective action planning for each case.
This Role Offers:
- Competitive base salary plus comprehensive benefits, including medical/dental/vision, 401(K), and more.
- Stable company with over seven decades of experience.
- Tight-knit culture focused on taking care of their employees.
- Ample opportunities for growth and career advancement.
- High employee tenure with low red tape culture. They hire professionals and trust their expertise, giving them room to make tangible impacts.
Focus:
- Achieve timely, accurate, and thorough resolution of A&G cases, while meeting performance standards and compliance requirements.
- Monitor consistency and quality of the team to measure compliance with regulatory and accreditation standards.
- Provide support and direction for the daily operations of the appeals function, leading internal team.
- Collaborate with appropriate staff to resolve member and provider complaints or grievances; formulate improvement measures and responses.
- Participate in audits, including document preparation and participation in on-site or remote audits, as a subject matter expert.
- Lead efforts to identify grievance and appeal case trends and conduct root cause analysis.
- Prepare monthly reports, logs, and other health plan or state requirements.
- Serve as the point of contact for issues that arise from members, providers and internal team.
- Communicate and partner with other departments, clients, vendors, and stakeholders.
Skill Set:
- 5+ years of healthcare experience in similar job functions.
- 2+ years of experience working within grievances and appeals; must have direct leadership background.
- Bachelor’s degree in a relevant field required.
- Strong computer skills in MS Office and database software.
- Firm understanding of processes surrounding benefits and managed care.
- Proven ability to manage conflict resolution by finding solutions and communicating effectively.
- Ability to implement process improvement initiatives and lead a team efficiently.
- Strong communication skills and ability to develop creative solutions to business challenges.
- Prior success managing compliance policies and procedures.
- Background in a fast-paced environment with proven ability to work well under pressure.
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