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Appeals and Grievance Manager
Amida Care
Description
The Appeals and Grievance Manager maintains responsibility for our grievance
and appeals processes. This position works with other departments to resolve member grievances and appeals and participates in training employees on member grievance and appeal rights, its process and timeframes, and how to assist members in filing a grievance or appeal.
RESPONSIBILITIES:
• Providing strategic leadership, expertise and support to teams in reviewing, researching, investigating, negotiating and resolving all types of appeals and grievances.
• Ensures that A&G compliance and processing needs are understood, and incorporated into the daily workflows for all departments.
• Works closely with compliance to ensure transactional processes meet regulatory requirements.
• Ensures that workflow reporting/ standards and metrics are established and communicated.
• Works across Amida Care and delegated entities to ensure that concerns are handled though appropriate escalation processes in order to meet both compliance and member needs.
• Drives process improvement.
• Develops and implements plans to achieve budget key operational metrics and provides daily reporting.
• Updates leadership on key patterns and emerging trends.
• Communicates complex information related to medical decisions and G&A; rules and regulations to internal and external customers.
• Develops staff to ensure internal bench strength, as well as the engagement and retention of employees across the teams.
REQUIREMENTS:
• BS/BA, advanced degree a plus, or comparable related work experience.
• Minimum of 5 years of experience in managed care with some Medicare appeals and grievance administration experience.
• Knowledge of Medicaid and CMS Regulations.
• Knowledge of Medicaid and CMS Regulations.
• Ability to travel as required.
Contact
https://home2.eease.adp.com/recruit/?id=12310622
Posted on 10/01/14; CVMHA ID #8201
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