Team Lead, Grievance & Appeals

CareSource•Ohio WFH, OH

2d•$62,700 - $100,400•Onsite

About The Position

The Team Lead, Grievance and Appeals oversees the day-to-day performance of grievance and appeals specialists, while ensuring all regulatory, compliance and HIPAA guidelines are met for Medicaid, Medicare and the Massachusetts Market.

Requirements

Associates Degree or equivalent years of relevant work experience required
Minimum of three (3) years of customer service experience in an HMO or related industry
Basic computer skills including Microsoft Word, Excel and PowerPoint
Basic experience with ACD systems
Basic experience with Call Management Systems
Communication skills
Ability to work independently and within a team environment
Attention to detail
Familiarity of the healthcare field and knowledge of Medicaid
Critical listening and thinking skills
Proper grammar usage
Technical writing skills
Time management skills
Proper phone etiquette
Customer service oriented
Decision making/problem solving skills
Strong language skills
Ability to write comprehensive statements using proper grammar and sentence structure

Nice To Haves

Previous supervisory/leadership experience preferred
Training/teaching skills
Strategic management skills
Negotiation skills/experience

Responsibilities

Supervise staff for quality review, performance feedback, disciplinary issues and merit/bonus appraisal review
Meet all monthly, annual and semi-annual reporting deadlines
Work with Regulatory Compliance Officers to ensure that requests are resolved within time lines and tracked for reporting
Monitor Medicaid and Medicare processes to ensure that all regulatory requirements are followed
Work with support departments and compliance officers to ensure policies and procedures are current
Establish an audit process
Responsible for evaluating operations and identifying process improvement needs.
Identify irregular trends with grievances and appeals; work with other areas as appropriate to identify root causes and appropriate steps for resolution
Responsible for staffing, ensure that open positions are filled, and evaluate future staffing needs
Review validation reports to ensure that grievances and appeals are accurate
Develop and monitor workflows for Grievance and Appeals Department that ensures maximum level of productivity
Monitor member-facing departments to ensure that grievances and appeals are resolved and reported to the Grievance and Appeals Department
Conduct audits and provide feedback to all areas that submit grievances and appeals
Facilitate timely resolution of member and provider issues.
Ensure that Grievance and Appeals Specialists are available to respond to incoming calls
Coordinate incoming information and disseminate to staff to ensure accuracy of communication to internal and external customers.
Create, review, revise and enforce company and departmental policies and procedures
Act as the contact point for CareSource on operational issues to all regulatory bodies in existing and future lines of business
Actively interact with IT department for immediate problem resolution and for coordination of data transmissions
Proactively keep the management team apprised of the team’s performance, projects and issues
Provide support to the Service Center during high call volume or other support as needed
Develop, deliver or coordinate the delivery of grievance and appeals training to other areas as needed.
Perform any other job related instructions, as requested