Director, Appeals & Grievances (Remote - Eastern Time Zone preferred)

About the position

Responsible for leading, organizing and directing the activities of the Grievance and Appeals Unit that is responsible for reviewing and resolving member and provider complaints and communicating resolutions to members and providers in accordance with the standards and requirements established by the Centers for Medicare and Medicaid.

Responsibilities

• Leads, organizes, and directs the activities of the Appeals & Grievances unit that is responsible for developing and delivering monthly and quarterly regulatory reports as well as analyzing and organizing data into meaningful reports for leadership decision making.
• Provides direct oversight and monitoring of the teams responsible for triaging member complaints, appeals and provider disputes in accordance with state regulations, federal requirements and Centers for Medicare and Medicaid standards.
• Oversees the regional quality audit and quality assurance program to ensure adherence with Medicaid and Medicare standards and requirements related to member complaints, appeals and provider disputes processing.
• Directs the assessing and auditing of business processes to determine those most effective and efficient at resolving member and provider problems while ensuring resolutions are compliant with timeframe and regulatory requirements.
• Establishes member and provider grievance/dispute and appeals policies/procedures and updates annually or as directed by the Centers for Medicare and Medicaid Services.
• Reviews and analyzes collective grievance and appeals data along with audit results on unit's performance; analyzes and interprets trends and prepares reports that identify root causes of member dissatisfaction; recommends and implements process improvements to achieve member/provider satisfaction or operational effectiveness/efficiencies.
• Serves as the primary interface with stakeholders and business partners. Collaborates with Compliance Officers and Government Contracts to oversee timely submission of state required reporting.
• Primary supports Ohio, New York, Mississippi and South Carolina.

Requirements

• Associate's Degree or 4 years of Medicare grievance and appeals experience.
• 7 years experience in healthcare claims review and/or member appeals and grievance processing/resolution, including 2 years in a manager role.
• Experience reviewing all types of medical claims (e.g. HCFA 1500, Outpatient/Inpatient UB92, Universal Claims, Stop Loss, Surgery, Anesthesia, high dollar complicated claims, COB and DRG/RCC pricing).
• 2 years supervisory/management experience with appeals/grievance processing within a managed care setting.

Benefits

• Competitive benefits and compensation package.