Director, Grievance & Appeals

Clayton, MO

Posted: 01/16/2019 Category: Other Area(s) Job Number: 24061
Description:
  • The position will be responsible for directing, managing and leading a team of over 100 specialists accountable to process Grievance and Appeal cases for the Medicare product.
  • Responsible for oversight of member appeals and grievance processes.
  • Efficient operational management of appeals and grievance departments/function with emphasis on execution, outcomes, continual improvement and performance enhancement.
  • Directs and ensures  the efficient operational management of appeals and grievance departments/function with emphasis on execution, outcomes, continual improvement and performance enhancement.
  • 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.
  • Performs other duties as required.
Qualifications:
  • Bachelor' s Degree in a related field or equivalent experience.
  • Master' s Degree preferred.
  • 5+ years of experience in grievances, appeals, or healthcare law related fields.
  • 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.
  • Medicare experience is highly preferred.
For more information on this position, please contact our office at 877-782-3334.

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