Appeals and Grievance Supervisor

UHS•Reno, NV

About The Position

Prominence Health is a value-based care organization that connects affiliated health systems and independent providers through trust and collaboration. It supports populations and providers by strengthening integrated partnerships, advancing market opportunities, and improving outcomes for patients and members. Founded in 1993 as a health maintenance organization and acquired by a UHS subsidiary in 2014, Prominence Health serves members, physicians, and health systems across Medicare, Medicare Advantage, Accountable Care Organizations, and commercial payer partnerships. The Appeals and Grievance Supervisor leads the Health Plan Operations appeals and grievance functions. The position ensures timely, accurate, and appropriate responses to inquiries, grievances, and appeals from members, providers, and regulators across all lines of business. It oversees the staffing, development, guidance, and daily supervision of the Grievance and Appeals team, and provides administrative support for investigating and resolving member complaints, grievances, and provider disputes. The supervisor trains staff, supports leadership in improving outcomes and operational efficiency, and collaborates with operational leaders to identify process improvements and maintain regulatory compliance.

Requirements

Two years of healthcare management experience, including increasing levels of responsibility.
Two years of experience working with health plan insurance products or employer healthcare benefits programs.
Two years of experience specific to grievances and appeals.
Four years of health plan or health insurance experience, including at least two years specific to grievances and appeals.
Associate’s degree or equivalent experience.
Knowledge of state and federal regulations applicable to the health insurance industry.
Experience reviewing and analyzing statistical data to identify trends and potential problems or opportunities to improve service quality.
Ability to communicate effectively in English, verbally and in writing.
Experience and/or training with computer applications, including Microsoft Word, Excel, and PowerPoint.
Ability to work and solve problems independently, take initiative to research and resolve processing and system issues using available resources, and offer improvement ideas and solutions.
Ability to organize people and activities.
Strong understanding of the claims analyst process, medical and dental terminology, and claims processing procedures.
Strong customer service skills, including identifying customer expectations and asking questions to determine the root cause of problems.
Excellent verbal and written communication skills, including communicating professionally with internal and external customers, facilitating meetings, conducting training, documenting workflows and processes, handling escalated calls, and responding to appeals.
Ability to understand how tasks and assignments contribute to broader goals, organize and prioritize work, follow up diligently with leaders, peers, departments, and customers, and make effective use of limited resources.

Responsibilities

Lead the Health Plan Operations appeals and grievance functions.
Ensure timely, accurate, and appropriate responses to inquiries, grievances, and appeals from members, providers, and regulators across all lines of business.
Manage staffing, development, guidance, and daily supervision of the Grievance and Appeals team.
Provide administrative support to investigate and resolve member complaints, member grievances, and provider disputes.
Train staff in the skills and knowledge needed for their roles.
Aid leadership in enhancing outcomes and operational efficiency.
Collaborate with operational leaders to identify process improvement opportunities and ensure consistent regulatory compliance.