Director, Grievance and Appeals – MIDWEST
Director, Grievance and Appeals will be a key player in the Medicare Operations Group and essential to the continued success of this thriving international business. Tremendous career opportunity.
Generous Relocation – UNLIMITED career growth – exceptional resources!
Position will be responsible for directing, managing and leading a team of over 100 specialists across 4 locations to process G & A cases for the Medicare product. Call Center will handle complaint and grievances primarily from the Members but with some Providers as well. Work closely with Medicare Compliance team. Director will be hands on , with the capability to conduct root cause analysis, identify and resolve potential risk.
-Oversight of member appeals and grievance processes, directing and ensuring the efficient operational management of appeals and grievance with emphasis on execution, outcomes, continual improvement and performance enhancement.
- Director participates on several internal committees to engage and offer input and guidance relative to risk assessment activities, impact of regulatory changes.
-Designs and implements processes, policies, trainings and procedures to ensure compliance with new and existing regulations.
-Addresses areas of below-standard performance and implements mechanisms to resolve risk management issues.
-Tracks and trends preventable issues and grievances and leads a committee focused on organization procedural improvements.
-Minimizes legal and financial risk by taking appropriate measures to protect the interest of providers, employers and members.
- Determines the potential loss and financial risk of unusual occurrence cases.
-Identifies need for in-house legal involvement on sensitive cases, and coordinates with plan attorneys on litigated cases, helping to oversee case preparation and research.
-Appears in court for small claims and administrative law judge cases to ensure appropriate representation of the Health Plan.
-Provides fiscal management and support including developing operational budgets and completing forecasts and variance reporting.
-Leads development of Business Area Requirement Reports (BARR) and business cases to ensure systematic capabilities and configuration.
-Acts as the point of contact for all areas of the Health Plan providing guidance, input and interpretation of policies, and ensuring compliance with internal and external requirements.
- Bachelor's Degree in a related field or equivalent experience. Master's Degree preferred.
-5+ years of experience in grievances, and appeals.
- Must have Medicare experience
-Previous management experience in managed care operations, including managing cross functional teams on large scale projects or supervisory experience including hiring, training, assigning work and managing the performance of staff
-CMS program audit experience is helpful.