Manager, Appeals & Grievances (Medicaid / Marketplace experience)

Grievance And Appeals Unit Leader

Responsible for leading, organizing and directing the activities of the Grievance and Appeals Unit that is responsible for reviewing and resolving member and provider complaints and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid.

Knowledge / Skills / Abilities :

• Manages staff responsible for the submission / resolution of member and provider inquiries, appeals and grievances for the Plan. Ensures resolutions are compliant.
• Proactively assesses and audits business processes to determine those most effective and efficient at resolving member and provider problems.
• Serves as primary interface with stakeholders and business partners and ensures standard processes are implemented.
• Oversees preparation of narratives, graphs, flowcharts, etc. to be used for committee presentations, audits and internal / external reports; oversees necessary correspondence in accordance with regulatory requirements.
• Maintains call tracking system of correspondence and outcomes for provider and member appeals / grievances; oversees monitoring of each member submission / resolution to ensure all internal and regulatory timelines are met.

Job Qualifications : Required Education :

Bachelor's degree or equivalent experience

Required Experience :

Min. 6 years' experience in healthcare claims review and / or member dispute resolution.

2 years leadership experience

Experience reviewing all types of medical claims (e.g. HCFA 1500, Outpatient / Inpatient UB92, Universal Claims, Stop Loss, Surgery, Anesthesia, high dollar complicated claims, COB and DRG / RCC pricing).