Grievance & Appeals Audit & Project Lead

EmblemHealth • New York, NY

310d • $72,000 - $138,000

About The Position

Coordinate all phases of Grievance and Appeal regulatory and accreditation audits including universe generation and case file compilation, during which all submissions are quality checked and risks are identified and mitigated to the extent possible. Serve as subject matter expert (SME) and liaison between business partners such as IT, Legal, Compliance. Analyze current processes against new regulations/requirements; make determinations on needed changes; collaborate with Leader and other department leadership and stakeholders to drive all necessary changes. Support the G&A Systems & Project Leader as a G&A systems (CAG) SME, responsible for submission and tracking of support tickets, conducting UAT and troubleshooting issues.

Requirements

• BS or BA degree
• 5 - 8+ years of relevant experience in Operations, preferably in a healthcare environment (Required)
• 3+ years of experience in grievance and appeals or related function (Preferred)
• Additional experience/specialized training/certification(s) may be considered in lieu of BS/BA degree (Required)
• 3+ years of audit experience (Preferred)
• Energy, drive and passion for end-to-end excellence and improvement (Required)
• Strong problem-solving and analytical skills that can be applied across all types of business problems (Required)
• Strong communications skills (verbal, written, presentation, facilitation, interpersonal) with all types/levels of audiences (Required)
• Excellent collaboration skills and the ability to influence management decisions (Required)
• Proficient in MS Office (Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc.) (Required)
• Ability to lead/manage multiple projects and cross-functional teams simultaneously (Required)
• Ability to clearly define and articulate project goals and objectives, and to measure outcomes (Required)

Nice To Haves

• Project Management (PMI) certification or Six Sigma/related certification or training preferred
• 3+ years of audit experience (Preferred)

Responsibilities

• Responsible for the fulfillment of G&A universe requests, including holistic validation, logic checks and quality review of all data elements.
• Interact with, respond to, and present to regulatory and accreditation auditors.
• Drive development of responses, through engagement with the G&A team, to any findings or requests for information, conducting applicable impact analysis and providing responses to regulatory and accreditation audit requests, meeting all deadlines.
• Ensure that all responses meet quality guidelines for completeness, accuracy, and timeliness.
• Letter administrator, responsible for development and programming of letter content, ensuring minimal manual updates to letters are required by G&A staff, thereby reducing risk of errors and increasing productivity.
• Responsible for continuous improvement of letter templates, implementing changes based on feedback and needs of the team.
• Provide expertise and vision with respect to planning, development and execution of G&A projects and implementations.
• Oversee/evaluate team activities and functions to ensure success and achievement of financial and timeline targets.
• Manage resources and priorities, risk mitigation, metric management, analysis, contingency planning, and reporting.
• Maintain solid knowledge and understanding of G&A processes and requirements to ensure projects are implemented appropriately and risks to the business are mitigated.
• Support G&A team to troubleshoot system issues, escalating to vendor as appropriate.
• Submit support desk tickets and track progress/completion, monitoring monthly support hour usage.
• Identify technology-based pain points and drive solutioning, increasing employee satisfaction by ensuring they have the optimal tools to complete job functions.
• Conduct UAT testing on a quarterly and/or ad-hoc basis to ensure business processes are behaving as intended and there is no impact to operations as a result of IT releases.

Benefits

• Hiring Range: $72,000-$138,000

What This Job Offers

• Industry: Insurance Carriers and Related Activities
• Education Level: Bachelor's degree