Manager, Complaints Grievances- Remote

UPMC•Pittsburgh, PA

5h•Remote

About The Position

UPMC Health Plan has an exciting opportunity for a Manager, Complaints Grievances position in the Member CGA department. This is a full time position working Monday through Friday daylight hours with rotating Saturdays that are on call. This is a remote position. This position is responsible for management of all member complaints and grievances and practitioner and provider complaints, for all products.

Requirements

Bachelor's degree in business, health care, management or a related field, or equivalent relevant experience required.
4 years (or more) of experience in process-oriented operations, or project-oriented management.
One (1) year of supervisory experience required.
Proven ability to manage processes in a health care setting with evidence of meeting established goals and outcomes.
Ability to manage staff and resources within established budget to achieve desired departmental goals.
High degree of organizational skills and problem-solving skills.
Excellent written and verbal and presentation skills
PC literacy (preferably Microsoft office products) - required

Nice To Haves

Managed care experience preferred.
Experience with member and practitioner complaint/grievance processes, preferred.
Strong project management skills and experience, implementing and managing cross functional projects preferred.
Experience with managed care preferred.
Licensed Registered Nurse - Preferred

Responsibilities

Responsible for the tracking, trending, analysis and reporting of member complaints, member grievances, and provider complaints.
Responsible for performing a root cause analysis and the initiation of corrective action plans where appropriate.
Responsible for ensuring review of monitoring reports is completed timely and accurately.
Serve as a role model of service excellence by ensuring adherence to established operational standards related to timeliness and accuracy.
Maintain a positive attitude, meets customer commitments and responds promptly to customer needs.
Manage the timeliness and accuracy of (member and provider) complaints and grievance reporting requirements for regulatory agencies, internal executive staff, and ad hoc reports as appropriate.
Manage activities relating to special projects for complaints and grievances.
Ensure compliance with work plans and goals.
Responsible for maintaining an integrated process to manage complaints and grievances with other departments within the Health Plan and with external delegated entities.
Ensure that the process, monitoring, and education process is supporting achievement of targeted results established by the Health Plan.
Manage the day to day operations of the member complaint, member grievance, and practitioner complaint process. This includes ensuring compliance with internal and regulatory standards and resolving complaints and grievances in a comprehensive manner.
Responsible for ensuring that second level hearings are in compliance with regulatory requirements and are performed in a professional, consistent manner.
Represent the Health Plan on internal and external forums/committees as requested.
Support implementation of appeals tracking system.
Responsible for the implementation and ongoing implementation of the member grievance and appeal processes related to the Medicare products
Develop and monitor corrective action plans both internal and cross departmental.
Responsible for ensuring processes are compliant with external regulatory bodies, as well as NCQA standards.