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Medicare Appeals and Grievance Supervisor

Medicare Appeals & Grievances Supervisor
Job Details
Job Type

Full-time

Remote Worker - N/A • Appeals Grievances
Description
Job Summary

The Appeals and Grievances Supervisor is responsible for managing, supporting, and having oversight of the Medicare Advantage Part C Appeals and Grievances team. This includes analyzing, evaluating, and implementing corrective measures to improve performance and ensure compliance with laws, regulations, and other accreditation requirements, as well as, executing upon the operational and strategic plans to achieve expected performance.

Major Work Activities

Ensure that the Appeals & Grievance department processes all appeals, grievances, and complaints in accordance with standards and the corporation’s policies and procedures
Serve as a resource to the team regarding escalated or complex issues, process and systems issues, and regulatory updates
Monitor and distribute team’s caseload and ensure adequate coverage including after hours and weekend coverage/on-call coverage
Monitor and evaluate performance standards and provide feedback and guidance of problem resolution
Supervise the day-to-day operations of the Appeals and Grievance (A&G) staff and functions within the department ensuring productivity and quality metrics are met
Carrying and managing a modified caseload when necessary
Manages and makes recommendations on the development, maintenance, and quality assurance of all appeals and grievance processes and systems consistent with the Centers for Medicare and Medicaid (CMS) requirements, HTA’s Standard Operating Procedures (SOP’s), and stated goals.
Develops, implements maintains, and reviews the adequacy of HTA’s appeals and grievance systems, reporting, policies, and functions to achieve stated goals, including, but not limited to, case resolution and timely responsiveness for all lines of business, provider, and member or other stakeholders, and applicable accreditation standards to ensure compliance with all relevant regulatory requirements pertaining to HTA
Works with all key departments and external partners (i.e. health networks and delegates) to ensure all are up to date with regulatory, departmental, and organizational changes impacting the grievance and appeals processes. Works with internal management staff, including medical directors, in the resolution of grievances and appeals.
Represents the A & G department at various meetings as applicable.
Ensure timely and effective data collection, summarization, integration, and reporting, including, but not limited to, productivity, status, and trend reports.
Participates in all audits related to grievance and appeals for all HTA programs.
Demonstrates the ability to lead and influence others positively to achieve desired goals of HTA
Continually seeks professional development through training, certifications, etc.
Participation in the staff selection process using clearly defined requirements in terms of education, experience, technical and performance skills.
Train and onboard new team members
Performs other duties as assigned



Requirements
Minimum Qualifications

Required Education

Bachelor’s Degree or three (3) or more years equivalent work experience

Required Experience

Two (2) or more years of direct management experience
Two (2) or more years of experience in healthcare operations
Experience in Medicare Part C or D appeals and grievances
Strong in Word, Excel, and PowerPoint
Required Vaccines

COVID-19
Annual Flu Vaccine
Knowledge, Skills, and Abilities

Knowledge of the Centers for Medicare & Medicaid Services Medicare Advantage Appeals and Grievances Requirements
Strong in the following competencies:

Decision Making/Judgment
Problem Solving/Analysis
Verbal and Written Communication and Presentation
Creativity/Innovation
Preferred Qualifications

Preferred Education

Master’s degree in business, nursing, or related field
Preferred Experience

Experience working with regulatory agencies (Center for Medicare & Medicaid Services)
Experience leading/ coordinating initiatives
Experience working with and managing vendors

Time:  Full time
Salary:  Salary
Category:  Administration

Updated: 10/29/2021 9:42:49 AM