• Manager, Health Exchange Grievance & Appeal

    Job Locations US-VA-Glen Allen
    Job ID
    2018-4976
  • About Us

    Don’t just find a job, find your WHY at a purpose-driven organization; discover a career at Virginia Premier.
    By blending quality benefits, affiliating with the world-renowned VCU Health System and offering career-advancing development programs, we allow our employees to focus on the meaningful work of improving and saving the lives of more than 200,000 people throughout the state of Virginia.
     
    At Virginia Premier, we are building an industry leading health care organization through dedicated teams that have heart, provide top-notch quality member services and embrace our mission of inspiring healthy living within the communities we serve. Our vision is to connect people to innovation, quality and affordable health care for all phases of life.
     
    If this sounds like you, read on!

    Overview

    POSITION OVERVIEW

    The Exchange Grievances & Appeals Manager is responsible for direct oversight of operational and personnel management activities of the Exchange 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, Accreditation team, Compliance, Regulatory team, Medical Management, and Claims staff.  This manager will ensure supervision, investigation and resolution of member and practitioner grievances and/or appeals pursuant to Virginia Premier’s internal policies and ensure compliance with regulatory requirements, include resolving grievances and/or appeals within the required timeframes. This position shall also be responsible for serving as the plan’s primary Exchange liaison for the members and practitioners grievances and/or appeals.

     

    Responsibilities

    POSITION DUTIES AND RESPONSIBILITIES

    • Plans and implements complex projects and programs to meet requirements for Exchange based 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.
    • Assists with training, in-services and quality audits as a result of plan, regulatory or accreditation requirements
    • 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.
    • 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 closely with all internal teams which may include Care Management, Pharmacy, Claims, and Network Development to ensure procedures are consistent with contractual benefits, established policies and procedures are followed, and to negotiate solutions and resolve conflicts.
    • 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.
    • Assists with accreditation related duties, as needed related to appeals
    • 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
    • Current, active, unrestricted nursing license (Preferred not required)  

    SPECIAL KNOWLEDGE AND/OR SKILLS

    • Management experience
    • Strong interpersonal skills
    • Exceptional interpersonal and problem solving skills
    • Positive and approachable demeanor
    • Strong written and oral communication skills
    • Conflict resolution and coaching techniques
    • 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
    • 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

    • 3-5 years of managing or leading a managed care team
    • Experience in a health care office environment
    • Strong working knowledge of regulations pertaining to grievances & appeals
    • Knowledge of complaint resolution, Health Exchange benefits, and cross-functional processes
    • Experience working with low income, indigent and/or disadvantaged populations

    PHYSICAL REQUIREMENTS

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

     

    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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