Manager II Grievance/Appeals RN
About The Position
Manager II Grievance/Appeals-RN Location: Ohio-Cincinnati, Columbus, Mason, or Seven Hills (Must be within commutable distance to one of the listed locations.) Hybrid 1: This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. The Manager II Grievance/Appeals is responsible for management oversight of grievances and appeals departmental units to investigate, resolve, and respond to grievances and appeals, manages inventory and production levels, and operational and plan risk, ensures quality, and regulatory compliance. How you will make an impact: Primary duties may include, but are not limited to: Coordinates Grievance and Appeals Committee Meetings and Member Panel Hearings. Leads grievance and appeals in regulated audits. Serves as a resource for complex issues and interpretation of claims, provider contracts and data, eligibility, member contracts, benefits, clinical decisions, pharmacy on pre-service and post service appeals and grievances related to non-clinical and clinical services, quality of service and quality of care issues including executive and regulatory grievances. Oversees and implements new subsystems, procedures, techniques and supports digital automation objectives. Analyzes and develops strategies by achieving performance thresholds within budgetary guidelines. Monitors trends and analyzes grievance and appeals data to identify and recommend plan and policy changes and to ensure state and federal regulatory compliance and resolution within the regulatory timeframes. Ensures programs support overall QI program and meet regulatory compliance/accreditation and the company standards. Hires, trains, coaches, counsels, and evaluates performance of direct reports.
Requirements
- Bachelor’s degree and a minimum of 5+ years grievance & appeals experience and a minimum of 3 years of management experience in the healthcare industry; or any combination of education and experience which would provide an equivalent background.
Nice To Haves
- Active unrestricted RN license required.
Responsibilities
- Coordinates Grievance and Appeals Committee Meetings and Member Panel Hearings.
- Leads grievance and appeals in regulated audits.
- Serves as a resource for complex issues and interpretation of claims, provider contracts and data, eligibility, member contracts, benefits, clinical decisions, pharmacy on pre-service and post service appeals and grievances related to non-clinical and clinical services, quality of service and quality of care issues including executive and regulatory grievances.
- Oversees and implements new subsystems, procedures, techniques and supports digital automation objectives.
- Analyzes and develops strategies by achieving performance thresholds within budgetary guidelines.
- Monitors trends and analyzes grievance and appeals data to identify and recommend plan and policy changes and to ensure state and federal regulatory compliance and resolution within the regulatory timeframes.
- Ensures programs support overall QI program and meet regulatory compliance/accreditation and the company standards.
- Hires, trains, coaches, counsels, and evaluates performance of direct reports.
Benefits
- In addition to your salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).
- merit increases
- paid holidays
- Paid Time Off
- incentive bonus programs (unless covered by a collective bargaining agreement)
- medical, dental, vision, short and long term disability benefits
- 401(k) +match
- stock purchase plan
- life insurance
- wellness programs and financial education resources
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What This Job Offers
Job Type
Full-time
Career Level
Manager
Number of Employees
5,001-10,000 employees
