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Supervisor of Appeals and Grievances

Network Health is seeking a Supervisor of Appeals and Grievances. This individual is accountable for the day to day operations of the Appeals and Grievances team, processes and procedures including but not limited to human resource management; oversight of appeals and grievance cases  to ensure compliance with statutory and regulatory requirements;  identification, development and maintenance of documented processes and procedures to maximize outcomes and operational  efficiency; facilitation of the Commercial Grievance Committee; participating in regulatory audits/monitoring/surveys and internal audit and monitoring activities; serve as the measure owner for applicable appeals and grievance measures (Star Ratings, NCQA); and supports the director on the Star Ratings Taskforce, ETF Steering Committee, and Quality Management Committee. 

Job Responsibilities:

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. Provides support and leadership to department staff while managing overall performance. Maximizes staff performance through regular team meetings, effective training, on-going 1:1 performance discussion, as well as formal performance review and meaningful development
Review regulatory updates and determine the effect on the appeals and grievance process and procedures for all lines of business.
Assists in the review of appeals and grievance processes and implements updates and changes requested or required by regulators.
Participates in regulatory reviews and audits (CMS Program Audit, OCI, NCQA Survey)
Collaborate with multiple internal and external stakeholders including but not limited to government agencies (NCQA, CMS, OCI), regulators’ contractors, providers, members and vendors.
Participate in organizational projects and collaborate with leader to develop strategies to implement initiatives to enhance processes and efficiencies involving appeals and grievance team
Gather appropriate appeal and grievance data for required internal and external reporting measures.
Monitors all regulatory reports including but not limited to associated Medicare Star Rating performance metrics.
Collaborates with leader on identifying and analyzing report trends and implementing action plans.
Facilitates member appeals and grievance committees as required by statute or regulation. Review information for meetings and hearings prepared by team.
Other duties as assigned

 Job Requirements:

Associate Degree Required.
Bachelor’s degree in health administration, business, nursing, or related field preferred
5+ years’ experience working for a health insurance organization or similar environment required.
2+ years’ experience in appeals and grievance preferred
2+ years’ experience of leadership experience

Time:  Full time
Salary:  Salary
Category:  Compliance

Updated: 7/27/2022 3:06:19 PM

Job Contact:
Jackie Rosen

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1570 Midway Pl
Menasha, WI 54952