Duties and Responsibilities:
Ensure management team is accurately monitoring performance through daily meetings, coaching, feedback, documentation and disciplinary actions in collaboration with the Intake Vendor.
Help Standardize and Optimize in how Appeals and Grievances are routed
Work with Providers and DSE on educating providers in how to submit Appeals timely and accurately.
Assist in leading the AOR / WOL Outreach team in coordination with the supervisor
Identify trends and recommend solutions for improvement.
Determine best practices and strategically deploy approaches to meet production, compliance and quality targets and to perform all Appeals & Grievances tasks
Manage, develop and engage team. Work with leadership to establish and implement departmental goals, establish monthly goal review process and implement a plan of action for identified gaps
Maintain delegated vendor relationship and ensure vendor performance and compliance measures are met
Institute and manage working relationships within various operational areas to identify and execute overall process improvements
Build partnerships with business areas across and outside of operations to improve communication and responsiveness to multiple conflicting resource demands
Diagnose and understand operational challenges in addition to skill gaps in order to provide leadership and management to the Appeals & Grievances team
Focused on clinical criteria for expedited cases
Drive the development of innovative tools and processes to assist in overall handling of Appeals & Grievances functions
Working with the delegated vendor to identify opportunities to increase the rate in which SLAs are met
Support use and updates of systems in place for delivery of quality of results
Maintain knowledge of industry trends, best practices and protocols. Collaborate and share best practices with other units comprising the enterprise to ensure general consistencies and enhancements
Additional duties as assigned
Minimum Qualifications:
Bachelor's degree from an accredited institution or equivalent work experience
Experience with appeals and grievance processing and compliance
Experience building and managing a team and leading work processes in a fast-paced environment
Experience preparing and delivering written and verbal information to multiple types of audiences
Demonstrated ability to work well with others, understand process flows and correlating platforms, recommend options and implement solutions
Experience setting direction for department and managing staff performance
Experience managing multiple concurrent priorities.
Proven ability to work across areas in an organization to yield results
Preferred Qualifications:
Extensive experience in the healthcare appeals experience
MBA or master's degree from an accredited institution with focus in training & development, education, business, or healthcare administration
Leadership experience in an focus area of operational excellence or audit
Management experience in an operational department within the healthcare industryfocused on clinical leadership
Experience developing strategy and processes for a department or function
Experience managing vendors as an extension of a core team. Familiar with creating accountable ownership of a vendor team
WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.
