Supervisor, Grievance & Appeals

• Referral bonus opportunities
• Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays
• Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life Disability
• Employer-matched retirement saving funds
• Personal and financial wellness programs
• Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care
• Generous tuition reimbursement for qualifying degrees
• Opportunities for professional growth and career advancement
• Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities

• Supervises the intake, investigation and resolution of appeals and grievances, member and provider, for the Managed Long Term Care, Medicare Advantage, and HIV Special Needs Plan (SNP) programs to be consistent with mandated regulatory processes and timeframes for each product.
• Responsible for ensuring the integrity of tracking logs and records documenting plan actions and timeframes for each appeal or grievance. Maintains and supervises weekend on-call appeal processes.
• Tracks grievances and appeals that are in process in the department, prioritizes workloads, workflow and execution of activities delegated to staff; directs/monitors/oversees resolution consistent with regulatory requirements and timeframes.
• Communicates with internal and external staff at all levels including but not limited to, Provider Relations, Claims, Medical Director, third party administrator, pharmacy benefit manager, to achieve resolution of appeals and grievances. Maintains readiness for DOH or CMS audit at all times.
• Ensures the accuracy and integrity of data collection and reporting systems to support analysis and reporting of grievances and appeals data for operations and for required CMS and DOH reporting. Assists as needed in analyses and reports on grievance and appeal activity for management, for committees and as required by regulation; analyzes trends and recommends departmental improvements.
• Supervises and tracks appeals external to the plan including cases with the CMS independent review entities and NYS Fair Hearings and External Appeals. Supervises investigations and prepares a recommended responses to grievances referred to the plan from regulatory entities including but not limited to the Department of Health, CMS and Department of Insurance.
• Supervises an oversight program for specialty subcontractors, new or incumbent, to whom the plan has delegated responsibility for conducting the grievance and appeal process. This includes review, analysis and auditing of subcontractors to evaluate compliance with delegated functions and with CMS or DOH regulatory requirements. Recommends and assists in development of audit criteria, conducts audits and prepares audit reports and recommends corrective action as needed; follows-up to ensure that corrective actions have been implemented.
• Responsible for the content of all written correspondence generated by the G&A department to providers, members and regulatory entities. Prepares and disseminates reports and correspondence to enrollees, providers, and program staff and management at all levels internally and externally.
• Assists in the development and implementation of policies, procedures and operational workflows related to grievances and appeals. Recommends and assists in the development of standards and criteria for monitoring compliance with regulatory requirements for the programs including VNS Health product lines. Monitors and analyzes process flow for timeliness and efficiencies across all programs.
• Stays abreast of changes to Medicaid and Medicare regulations. Identifies and recommends changes to plan grievance and appeal operations accordingly.
• Identifies, recommends, and develops action plans to improve grievance and appeal workflows and processes, service performance, regulatory compliance and quality standards.
• Serves as a resource on grievances, appeals and external reviews. Identifies and recommends key areas for training and coaching of staff based on departmental monitoring and oversight. Maintains and oversees staff leave schedules, ensures adequate staff coverage for departmental functions year-round, and holiday and weekend coverage.
• Performs all duties inherent in a supervisory role. Recommends hiring, salary actions, promotions, termination and performs orientation/training to facilitate the professional growth and development of assigned staff.
• Participates in special projects and performs other duties as assigned.

Education:
Bachelor's Degree in health/human services, business administration or related discipline, or equivalent work experience required. Master's Degree in public health or health-related field preferred

Work Experience:
Minimum of three years experience in health care required Minimum of two years experience with Grievance and Appeals in a Medicare and/or Medicaid managed care setting required. Experience in a supervisory role preferred Excellent oral and written communication skills required Computer literacy including word processing, spreadsheet applications, and database applications required. Experience with MS Office required Experience with FACETS system preferred