Appeals and Grievances Team Leader- Remote

TruHealth•Franklin, TN

8h•Remote

About The Position

The purpose of this position is to provide lead level support to the Appeals and Grievances team with the direct assistance of the Director of Claims Operations. The purpose of the position includes overseeing the processing, tracking, and following up on all medical necessity and administrative denials, appeals, grievances, and disputes for Medicare Advantage members in accordance with Medicare guidelines and regulations. The Appeals and Grievances Team Leader is a critical team player who works in a fast-paced, ever-changing environment with a passionate team and must deliver daily.

Requirements

Excellent communication skills and active listening
Positive, engaging customer service skills
Meet critical time frames on a frequent and regular basis
Work cooperatively with internal departments and external stakeholders
Perform in potentially stressful situations, such as state, federal, NCQA, URAC or other regulatory/accrediting agency audits
Minimum (3) three years’ health plan experience; insurance, compliance, managed care, or quality assurance preferred
Minimum (3) years of Grievance and appeals experience preferred, specifically within a Medicare and/or Medicare Advantage context
Minimum two years of demonstrated leadership skills in claims and/or appeals and grievances
Proven track record for improving processes and problem-solving skills
Ability to motivate team members while also possessing strong leadership skills
Knowledge and understanding of complaint and appeal procedures
Knowledge of managed care, particularly utilization management processes
Knowledge of NCQA, HEDIS or general accreditation requirements and guidelines for utilization management, denials and appeals
Familiarity with Appeals processes and regulatory requirements related to
Customer service experience
Proven ability to problem-solve and make solid and well-researched decisions
Qualifying criminal background

Nice To Haves

Associates degree preferred
Successfully completed college courses in relevant fields to compensate for experience preferred
Medicare experience preferred
Experience working with physicians and clinicians in the appeals and grievance space, preferred

Responsibilities

Capture, investigate and respond to all complaints regarding customer grievances and appeals in addition to overseeing claim payment disputes provision of service and benefit coverage issues
Conduct pertinent research to evaluate, answer, and close appeals
Ensure appropriate resolution to inquiries, grievances and appeals within specified timeframes established by either regulatory/accreditation agencies or customer needs; ensure appropriateness of the response in compliance with State and Federal guidelines
Assist members when filing appeals; educate members, document and route the information appropriately
Prepare response letters, notifications, and acknowledgements for members and provider complaints, grievances and appeals
Maintain grievance information and supporting documentation in accordance with all state, federal, NCQA, URAC and other regulatory agency standards / regulations
Escalate issues appropriately or work with other departments to resolve member issues
Ensure all HIPAA and State requirements/regulations are always adhered to
Identify issues and root causes of appeals and disputes for plan management and compliance
Identify and report trends and/or areas of opportunities to supervisor
Maintain and update appeal and grievance policies and procedures, member correspondence materials, and process manuals
Perform internal audits of grievance and appeals process
Maintain privacy and confidentiality of records, conditions, and other information relating to residents, employees and facility
Encourage an atmosphere of optimism, warmth and interest in patients’ personal and health care needs
Meet critical time frames on a frequent and regular basis