Director, Grievance and Appeals(Preferred Experience In Managed Care)
About The Position
The Director, Grievance and Appeals oversees appeals and grievance processes and directs the efficient operational management of the department or function, with emphasis on execution, outcomes, continual improvement, and performance enhancement. The role designs and implements processes, policies, training, and procedures to ensure compliance with new and existing regulations; addresses below-standard performance; and tracks preventable appeals and grievances to present findings to Operations leadership. The Director minimizes legal and financial risk while protecting the interests of members and providers. This includes identifying cases requiring in-house legal involvement and coordinating with plan attorneys on litigated cases, including case preparation and research. The role also provides fiscal management through budget development, forecasting, and variance reporting; ensures appropriate systems and technology support compliance, quality, and operational efficiency; analyzes data to identify process improvements; coordinates grievance and appeal committee meetings; and maintains cohesive relationships with internal partners. Other duties may be assigned.
Requirements
- Bachelor of Arts or Bachelor of Science degree, or equivalent years of work experience.
- At least five years of management experience.
- Managed care experience.
- Direct leadership experience in a healthcare operational grievance and appeals environment.
- Customer service skills and the ability to interact professionally and effectively with members, providers, internal business areas, and colleagues.
- Strong analytical skills, including the ability to create reports and interpret operational, utilization, and financial data.
- Problem-solving skills, including identifying root causes and developing workable solutions.
- Computer proficiency and experience in a Windows environment.
- Ability to maintain regulatory knowledge for compliance.
- Strong written and verbal communication skills.
- Ability to work in a fast-paced environment.
- Decision-making and problem-solving skills.
Nice To Haves
- Master’s degree.
- Senior management experience.
- Managed care experience is preferred.
Responsibilities
- Oversee appeals and grievance processes and direct efficient operational management of the department or function.
- Design and implement processes, policies, training, and procedures to ensure compliance with new and existing regulations.
- Address below-standard performance and implement mechanisms to bring performance up to standard.
- Track and trend preventable appeals and grievances, and present findings to Operations leadership.
- Minimize legal and financial risk while protecting the interests of members and providers.
- Identify cases requiring in-house legal involvement and coordinate with plan attorneys on litigated cases, including case preparation and research.
- Develop operational budgets and complete forecasts and variance reporting.
- Ensure systems and technology support compliance, quality, and operational efficiency.
- Analyze data regularly to identify and implement process improvements.
- Coordinate grievance and appeal committee meetings with appropriate parties.
- Establish and maintain cohesive relationships with internal partners.
- Perform other job duties as requested.
Benefits
- May qualify for a bonus tied to company and individual performance.
- Substantial and comprehensive total rewards package.
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What This Job Offers
Job Type
Full-time
Career Level
Director
