Manager, Appeals & Grievances

Blue Cross Blue Shield of Minnesota•Eagan, MN

3d•Hybrid

About The Position

In this positions, you will develop, implement, continuously monitor, and improve processes and programs to reduce appeals and grievance inventory while providing guidance, support, and solutions for team(s) on a breath of activities. In this position, it will require client-facing, problem solving, analytical, continuous improvement, change management, and execution skills. You will serve as an expert resource for complex issues, interpretation of regulatory standards, and both internal and external audits. You will be accountable for the daily activities of the department and own the escalated corporate appeal process to meet objectives of timeliness, thoroughness, consistency, and compliance requirements. You will identify and evaluates appeal trends and implement strategies and tactics to assist in shaping future efforts. In this position, you will be responsible for leading and overseeing projects and initiatives that impact appeals and grievances. Serves as a lead role in corporate and mandated initiatives, this position drives changes, effectively communicates, develops business rules, enforces regulatory requirements, and regulates workflow processes to ensure systems and support are in place for proper appeals handling.

Requirements

5+ years of progressive customer service/operations experience, with 1+ staff, team lead or project lead experience.
Bachelor’s degree; in lieu of a degree, an additional two years of relevant experience beyond the qualifications listed above may be accepted.

Nice To Haves

Masters degree in related field.
Ability to communicate expectations and priorities clearly to team members, actively listen to resolve issues and remove barriers, and drive alignment across teams and stakeholders.
Ability to analyze department challenges, guide team decision-making, and collaborate across teams to drive resolution and next steps.
Ability to effectively organize team work, balance priorities across projects, and manage time and resources to ensure timely delivery and coordination.
Knowledge of state and/or federal regulatory policies and/or provider agreements, and a variety of health plan products.
Experience with Medicare, Medicaid, service and issue resolution.
Knowledge of Health Plan operations including claims, enrollment, sales and marketing, health services and membership.

Responsibilities

Identifies and evaluates appeal trends and implements strategies and tactics to assist in shaping future efforts while ensuring we remain in compliance with department objectives and regulatory and compliance requirements.
Owns the escalated corporate appeal process (pre and post review) for the Corporate Appeals Committee. This includes but is not limited to legal, medical professionals, senior leaders, and includes external legal counsel and providers.
Lead and/or provide business ownership and subject matter expertise for internal workgroups/committees in support of core and strategic projects that affect business workflow requirements and vendor relationships, including processes and rules.
Participates in the evaluation, selection, and drives implementation of new technical solutions to increase the efficiency and new capabilities within the team.
Serve as a change agent by championing organizational initiatives, leading teams through change, and fostering a culture of adaptability, continuous improvement, and innovation.
Lead transformational change by identifying, analyzing, and implementing solutions for potential pain points through continuous improvement activities in order to improve the associate and member/provider experience.
Analyze appeals operational reporting and communicates trend analysis and opportunities for process improvements to senior leadership and business partners at all levels.
Establish and maintain a positive, collaborative working relationship with enterprise business partners, including, but not limited to Customer Service, Care Management, Claims, Compliance and Network Management to ensure processes are streamlined and efficient.
Work strategically with new and existing vendors to ensure appeals processes continue to remain compliant with regulatory requirements and to ensure opportunities are capitalized on and the effects of competitive activity are minimized, relative to brand message and position.
Partner directly with compliance teams and other internal audit teams to ensure that new regulatory requirements are implemented, and the appeals team members continue to maintain audit readiness.
Provide strategic direction to all associates for questions regarding processes, projects, and/or data.
Manage the allocation of resources, including staff and technology, to meet corporate objectives, and regulatory/contractual requirements for handling appeals to ensure compliance with state, federal and accreditation requirements.
Conducts performance evaluation, and is responsible for managing employees, including skill and career development, policy administration, coaching on performance management and behavior, employee relations and cost control.
Identify and execute staff training plans, including the development of training modules/materials.
Performs additional responsibilities consistent with the scope and level of the role, as assigned.