Supervisor, Appeals and Grievances

L.A. Care Health Plan•Los Angeles, CA

3d•$77,265 - $123,625•Hybrid

About The Position

The Supervisor, Appeals and Grievances is responsible for direct supervision and support of the team responsible for the intake, research, resolution, tracking, trending and reporting within the Appeals and Grievances department. This position will be accountable for leading and directing the work for the Appeals and Grievances department by monitoring the research, negotiation and resolution of all types of appeals and grievances to ensure thorough investigations are completed as outlined in the company policies and procedures. Provides support and ownership of cases identified as escalated, complex and/or multi-issue appeals and grievances on an as needed basis. Collaborates with internal departments to ensure timely resolution. This position will be responsible for analyzing and trending for all appeals and grievances. Responsible for the development and maintenance of the appeal and grievance Policies and Procedures (P&Ps), workflows, Member correspondence, and training as needed, or on an annual basis. The position supervises all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports. Responsible for supervising daily operations that includes setting goals, evaluating performance and addressing issues. Ensure the team's efforts align with organizational goals and objectives.

Requirements

At least 3 years in a healthcare setting in Grievances and Appeals, Compliance, Claims or Call Center.
At least 2 years of leading process, program, or staff or supervisory experience.
Ability to manage and organize large volumes of data.
Knowledge of regulatory and accreditation entities and their requirements.
Excellent verbal and written communication skills and interpersonal skills.
Good working knowledge of licensure and regulatory requirements, and accreditation standards.
Ability to work independently.
Ability to solve complex issues and identify creative solutions.
Computer ease and literacy with Microsoft Office (Word, Excel, Power Point, Access, and Visio).
Skilled in leading, mentoring, and developing staff.
Proficient in overseeing operations and managing resources.
Ability to plan and make decisions that align with organizational goals.
Skilled in handling paperwork, budgets, and reports.
Strong motivational skills.

Nice To Haves

Master's Degree
Previous experience in Managed Health, preferably in Customer Service, Appeals and Grievances and/or Claims.
Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.

Responsibilities

Evaluate daily reports to ensure individual and team Key Performance Indicators (KPIs), Service Level Agreements (SLAs), Performance Scorecards meet regulatory requirements.
Provide direction to staff for complex/sensitive member and provider inquiries, concerns, complaints, appeals, and grievances.
Conduct weekly 1:1s with direct reports.
Build and maintain strong working relationships with internal departments involved in appeal and grievance resolution.
Develop, maintain and implement P&Ps, workflow and training.
Audit preparation and providing recommendations for Corrective Action Plans from state regulatory agencies.
Supervise staff, including, but not limited to monitoring day-to-day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others.
Responsible for creating the schedules for assigned staff.
Provide ongoing development opportunities for their assigned staff.
Assist and recommend in the establishment of performance goals, communicating to the assigned staff.
Ensure team complies with organizational and regulatory standards.
Responsible for addressing issues, resolving disputes, and ensuring compliance with policies and procedures.
Responsible for allocating resources effectively and ensuring optimal utilization.
Responsible for administrative work, including reporting, budgeting, and policy implementation.
Perform other duties as assigned.