Utilization Management, Grievance and Appeals Operations Manager - Denver Health Medical Plan

We are recruiting for a Utilization Management, Grievance and Appeals Operations Manager - Denver Health Medical Plan to join our team!

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Department

Managed Care Administration

*Remote Opportunity. Must Live in Colorado.

Job Summary

The Manager, Health Plan Business Operations for Grievances and Appeals is responsible for managing health plan operations and regulatory compliance with emphasis on grievances and appeals, utilization management and claims processing. Oversees review, investigation, documentation, processing, negotiating and resolving disputed medical insurance claims per federal and state regulatory requirements. Facilitates and participates in internal monitoring for compliance and regulatory audits. Provides oversight for administrative functions and management of the department, including personnel and financial management.

Committed to continuous improvement and learning. Analyzes and evaluates service for quality improvement including productivity, strategic planning, budget management, and development of performance standards. Manages staff and productivity to ensure effective and balanced case workload. Builds and manages effective partnerships that engage stakeholders in understanding the issues, identifying opportunities and assisting with resolution. Ensure that department's milestones/goals are met and adhering to approved budgets.

Essential Functions :

• Leads operational services of department including personnel and financial management. (30%)
• Analyzes for regulatory compliance for all lines of business. Assists with regulatory audits. (10%)
• Establishes qualifications and performance standards for each position as well as coaches and develops staff members to ensure employee performance. (10%)
• Assesses quality of services regularly according to prescribed quality assessment methods and ensures those services are continuously improved. (10%)
• Develop Standards of Work (SOW) documentation, policies, and procedures for assigned department. (10%)
• Develops and manages Key Performance Indicators (KPIs) designed to promote optimal success and efficiency. (10%)
• Assists with developing annual operational and capital budgets and ensures that the department operates within prescribed budgetary parameters. (10%)
• May manage contracts and contract relationships with customers/clients and vendors. (10%)

Education :

• Associate's Degree from an accredited school in business, healthcare or related field. Required or
• Bachelor's Degree from an accredited school in business, healthcare or related field.

Work Experience :

• Four to six years of health plan operations . Project or professional management in areas such as billing/financial regulations, planning and development, setting operational objectives, human resource management, business forecasting, budget development required.

Licenses :
Knowledge, Skills and Abilities :

• Values and attributes that show empathy, display resilience and show sound judgement in claims management. Build and manage effective partnerships that engage stakeholders in understanding the issues, identifying innovative solutions and in supporting best practice claim management outcomes.
• Highly skilled in budget preparation/financial analysis, decision making regarding appropriateness of care review, assist with research design planning, and analyzing and generating quality improvement reports.
• Ability to work independently as well as collaboratively with other internal and external team members to ensure timelines are met.
• Knowledge of personnel management, management of budgets, strategic planning involving collaboration with outside agencies or business entities.
• Ability to communicate and maintain effective working relationships with subordinates, medical staff, administration, and other departments.
• Knowledge and problem-solving process.
• Extraordinary emotional intelligence and quotient, professional communications, interpersonal skills and ability to build genuine trust relationships throughout the organization and beyond.
• Able to lead, manage, advise, mentor, direct and evaluate employees with grace, fairness and accountability.
• Requires strong organizational skills to set priorities and ability to work with high degree of accuracy and attention to details while responding to tight deadlines and multiple priorities and demands.

Shift

Days (United States of America)

Work Type

Regular

Salary

$86, - $130, / yr

Benefits

• Outstanding benefits including up to 27 paid days off per year, immediate retirement plan employer contribution up to , and generous medical plans

• Free RTD EcoPass (public transportation)

• On-site employee fitness center and wellness classes

• Childcare discount programs & exclusive perks on large brands, travel, and more

• Tuition reimbursement & assistance

• Education & development opportunities including career pathways and coaching

• Professional clinical advancement program & shared governance

• Public Service Loan Forgiveness (PSLF) eligible employer+ free student loan coaching and assistance navigating the PSLF programÂ

• National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer

Our Values

• Respect

• Belonging

• Accountability

• Transparency

Denver Health values the unique ideas, talents and contributions reflective of the needs of our community. For more about our commitment to diversity visit: