Virginia Premier Health Plan, Inc.

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Manager, Medicare Grievance & Appeals

Manager, Medicare Grievance & Appeals

Job Locations 
US-VA-Glen Allen
Job ID 
2017-4045

Job Description

Overview

The Medicare Grievances & Appeals Manager is responsible for direct oversight of operational and personnel management activities of the Medicare Grievances & Appeals team. The manager will ensure that plan members and practitioners are educated on how to properly submit a formal grievance and/or appeal in a timely manner.  The manager will participate in quality improvement activities related to grievances and/or appeals, interacting closely with Medical Directors, Quality team, Compliance, Regulatory, Medical Management, as well as Claims staff.  This manager will ensure supervision, investigation and resolution of member and practitioner grievances and/or appeals pursuant to Center for Medicare and Medicaid Services (CMS), Department of Medical Assistance Services (DMAS), and National Committee for Quality Assurance (NCQA), to include resolving grievances and/or appeals within the required timeframes. This position shall also be responsible for serving as the plan’s primary Medicare liaison for the members and practitioners grievances and/or appeals. 

Responsibilities

  • Plans and implements complex projects and programs to meet requirements for regulatory Medicare audits, regulatory compliance projects and internal monitoring and compliance initiatives.
  • Creates and maintains a high quality and productive team environment to keep appeals and grievances team motivated to perform at their highest level.
  • Leads and/or participates in cross-functional teams and committees to ensure comprehensive and coordinated efforts to remediate issues identified in appeals and grievances and facilitates process improvements throughout the organization, but specifically in the areas of customer service, claims, care management, and provider relations.
  • Manages employee performance while motivating and coaching staff to achieve compliance and positively influence STARS ratings.
  • Monitors changes to regulatory guidance to support revisions to department workflows, systems, training, desk procedures and policies.
  • Responsible for ensuring staff are accurately updated related to new, revised, amended and/or deleted plan, regulatory and/or accreditation requirements.
  • Works with internal committees and departments (i.e., Quality, Network Development, etc.) to review and analyze appeal and grievance trends and recommend corrective action as necessary.
  • Responsible for maintaining and updating on an annual basis, or as necessary, appeal and grievance policies and procedures, member correspondence, etc., consistent with regulatory changes.
  • Prepare, attend and present grievances and/or appeals documentation for hearings, panels and audits.
  • Ensures all appeals and grievances are documented, tracked and resolved in a timely and accurately manner, according to regulatory and accreditation timeframes
  • Provides detailed reporting of risk management issues to department leadership and corporate compliance team within the specified timeframe.
  • Oversees the process for responding to regulators and CMS to maintain continuous process improvement and effective monitoring for Independent Medical Reviews, Consumer Complaints, State Fair Hearings, Administrative Law Judge hearings, IRE and QIO submissions and effectuations.
  • Ensures consistent and ongoing policy and procedure reviews, education, training and in-services regarding the member and practitioner grievances/appeals processes.

 

Qualifications

MINIMUM EDUCATION REQUIREMENTS

  • B.S. degree preferred in Business, Health Care Administration or related discipline   

SPECIAL KNOWLEDGE AND/OR SKILLS

  • Exceptional interpersonal and problem solving skills
  • Positive and approachable demeanor
  • Strong written and oral communication skills
  • Strong analytical and conflict resolutions skills as well as persuasion skills. 
  • Proficient in MS Office applications (Word, Excel, Power Point)
  • Demonstrates exemplary leadership with exceptional work ethic.
  • Ability to prioritize and work under pressure
  • Subject matter expertise in Medicare Advantage and Part D rules and requirements
  • Experience in member or patient complaints or regulatory compliance investigations preferred
  • Understanding of operational process flow analysis and process improvement methods
  • Experience working with firm deadlines with the ability to interpret and apply regulations. 

WORK BACKGROUND/EXPERIENCE

  • Management Experience (3+ years required)
  • Strong knowledge of CMS regulations pertaining to grievances & appeals 

PHYSICAL REQUIREMENTS

  • Physical health sufficient to meet the ergonomic standards and demands of the position 

About Us

Virginia Premier Health Plan, Inc. is a managed care organization which began as a full-service Medicaid MCO in 1995. Partnered with VCU Medical Systems we strive to meet the needs of the underserved and vulnerable populations in Virginia by delivering quality driven, culturally sensitive and financially viable Medicare and Medicaid healthcare programs.  Headquartered in Richmond, VA we also have offices in Roanoke, Tidewater and Bristol with additional satellite locations allowing us to serve over 200,000 members across eighty counties throughout Virginia. 

 

We offer competitive salaries and a comprehensive benefits package to include excellent Medical, Dental and Vision Plans, Tuition Assistance, Infant-At-Work Program, Remote Work options and generous vacation and sick leave policies. Our culture supports an environment where employees can continuously learn and gain professional growth through various development programs, education, exciting projects and career mobility.  

 

All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. EOE

 

Our mission is to inspire healthy living within the communities we serve!

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