Manager, Grievance and Appeals, RN

About the position

VNS Health Plans is seeking a dedicated Manager, Grievance and Appeals (RN) to lead the daily operations of our grievance and appeals processes. You will play a crucial role in overseeing staff interactions and ensuring that our members' voices are heard, their concerns are addressed, and that we continuously improve our services. This position involves managing day-to-day activities for staff handling grievances and appeals across our Managed Long Term Care (MLTC), Medicare Advantage (MA), or Select Health product lines, ensuring compliance with state and federal regulations, and collaborating with subcontractors to maintain high standards for operational and regulatory compliance. You will also be responsible for maintaining the integrity of case files and data collection systems, preparing insightful reports and analyses that inform program management and committee decisions. The role offers a mostly remote work environment with just one day a month in the office, allowing for a work-life balance while contributing to meaningful change.

Responsibilities

• Manage day-to-day activities for staff handling grievances and appeals across MLTC, MA, or Select Health product lines.
• Ensure compliance with state and federal regulations.
• Collaborate with subcontractors to ensure operational and regulatory compliance in managing grievances and appeals.
• Maintain the integrity of case files and data collection systems.
• Prepare reports and analyses that inform program management and committee decisions.
• Oversee clinical appeals review processes within the Appeals & Grievances Department.
• Manage the intake, investigation, and resolution of member grievances and appeals.
• Maintain readiness for DOH or CMS audits at all times.
• Act as a subject matter expert to internal departments and delegated vendors.
• Track grievances and appeals in process and ensure the integrity of tracking logs and records.
• Communicate with corporate and regional staff to achieve resolution of appeals and grievances.
• Ensure accuracy and integrity of data collection and reporting systems.
• Participate in analyses and reports on grievance and appeal activity for management and regulatory entities.
• Analyze trends and recommend departmental improvements.
• Manage and track appeals external to the plan.
• Supervise investigations and prepare recommended responses to grievances referred from regulatory entities.
• Manage specialty subcontractor program for delegated grievance and appeal responsibilities.
• Conduct audits and prepare audit reports; recommend corrective actions as needed.
• Prepare and disseminate reports and correspondence to enrollees, providers, and regulatory entities.
• Assist in the development and implementation of policies, procedures, and operational workflows related to grievances and appeals.
• Monitor and analyze process flow for timeliness and efficiencies.
• Keep up to date on regulatory issues and trends in governing VNS Health Plans products.
• Identify and recommend changes to plan grievance and appeal operations.
• Identify, recommend, and develop action plans to improve workflows and processes.
• Serve as a resource on grievances, appeals, and external reviews.
• Identify and recommend key areas for training and coaching of staff.
• Maintain and oversee staff leave schedules and ensure adequate staff coverage.
• Maintain and supervise weekend on-call appeal processes.
• Perform all duties inherent in a managerial role.
• Ensure effective staff training, evaluate staff performance, and participate in budget development.

Requirements

• License and current registration to practice as a registered professional nurse in New York State required.
• Associate's Degree in Nursing required; Bachelor's Degree in Nursing preferred.
• Minimum of five years' progressive professional experience in healthcare required.
• Minimum of three years' experience in a Grievance and Appeals or related area in a Managed Care setting required.
• Experience in a supervisory role preferred.
• Excellent oral and written communication skills required.
• Computer literacy including word processing, spreadsheet applications, and database applications required.
• MS Office preferred.
• Experience with FACETS system preferred.

Nice-to-haves

• Experience in a supervisory role preferred.

Benefits

• Referral bonus opportunities
• Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays
• Health insurance plan for you and your loved ones, including Medical, Dental, Vision, Life and Disability
• Employer-matched retirement saving funds
• Personal and financial wellness programs
• Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care
• Generous tuition reimbursement for qualifying degrees
• Opportunities for professional growth and career advancement
• Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities