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Manager of Appeals and Grievances

Network Health is seeking a Manager, Appeals and Grievance. This individual is accountable for the day to day operations of the Appeals and Grievances department and process including but not limited to human resource management, oversight of appeals and grievance investigations to ensure compliance with legal and regulatory requirements, and identification, development and maintenance of procedures to maximize outcomes and operational efficiency. The Manager of Appeals and Grievances may provide regulatory expertise and structure surrounding expedited appeal/ reconsideration and quality of care concerns. The manager will participate in audits with both internal and external vendors such as CMS, NCQA etc. on behalf of the appeals and grievance department and speak to department processes and procedures

Essential Job Duties:
• Demonstrate commitment and behavior aligned with the philosophy, mission, values and vision of Network Health
• Appropriately apply all organizational, regulatory, and credentialing principles, procedures, requirements, regulations, and policies
• Performs human resource management duties including but not limited to hiring, training, retraining, and time and performance management. Consults with leader and Human Resources as required
• Review regulatory updates and determine the effect on the appeals and grievance process and procedures for all lines of business. Stay current with updates from government agencies regarding regulatory processes the organization may need to update to remain in compliance.
• Assists in the review of appeals and grievance processes working to institute changes required by regulatory bodies.
• Collaborate with multiple internal and external stakeholders including but not limited to: government agencies (NCQA and CMS and OCI), providers, and vendors.
• Assess, implement, and respond to regulatory agency requests for process review and update
• Participate in organizational projects as well as develop strategies to implement new projects or initiatives to enhance processes involving appeals and grievance department
• Establish and maintain a collaborative team environment that ensures efficiency and yields productivity
• Provide support and leadership to department staff while managing overall performance. Maximizes staff performance through regular team meetings, effective training, on-going 1:1 performance discussions, as well as formal performance review and meaningful development
• Gathers appropriate data for various reporting measures inside and outside the organization. Report appeal findings to department leaders based on results of member complaints or appeal process. Assemble appropriate annual reporting for regulated agencies, including CMS and other vendors.
• Based on trend analysis identifies action plans to optimize performance. Monitors all regulatory reports including but not limited to the CMS complaint tracking modules for both Medicare and Health Insurance Exchange, and associated Medicare Star and QRS performance metrics
• Facilitates member appeals and grievance committees as required by applicable law. Review information for meetings and hearings prepared by team.
• Other duties as assigned

Knowledge/Skills/Abilities Required:
• Strong oral and written communication skills with the ability to listen mindfully, identify gaps and ask appropriate questions
• Ability to organize one’s work and space to ensure successful completion of assigned tasks within the identified timeframe
• Ability to adapt to new circumstances, information and challenges in a fast-paced environment
• Ability to work independently, as well as part of a team
• A well-organized and self-directed individual who is able to work with minimal amount of supervision
• Capable to efficiently complete tasks and ability to manage multiple priorities under pressure
• A decisive individual who possesses a strategic focus as well as an operational, implementation and detail oriented perspective
• Sound technical skills, analytical ability, good judgment, and strong operational focus
• Excellent professional research, analysis and problem-solving skills
• Knowledge of regulatory/accreditation requirements for grievance & appeals (CMS/NCQA/OCI)
• Excellent written and verbal skills, with the ability to write complex letters and reports and make effective verbal presentations related to grievance & appeals
• Intermediate skills in Microsoft Office Suite, including Access, Excel, Outlook, and Word. Familiarity with PowerPoint desired
• Familiar with state or federal appeals and grievances process or regulations

Minimum Education Required:
• Associate Degree Required.
• Bachelor’s degree in health administration, business, nursing, or related field preferred

Minimum Related Years of Experience (per minimum education) Required:
• 5+ years’ experience working for a health insurance carrier or similar environment required.
• 2+ years’ experience in appeals and grievance required
• 2+ years’ experience of leadership experience
• Experience working as a registered nurse strongly considered.

Time:  Full time
Salary:  Salary
Category:  Compliance

Updated: 9/26/2018 11:27:40 AM

Job Contact:
Jackie Rosen
9207201723

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1570 Midway Pl
Menasha, WI 54952

9207201723