Appeals and Grievance Supervisor

Prominence-Health-Plan; Reno (NV); On-site; USD 90,000 - 125,000; Full time

Benefits offered by this job

Loan Forgiveness

Rewarding work environment

Competitive compensation

Paid time off

Health plans (Medical, Dental, Vision,

401(k) with match

SoFi loan refinancing

Career development

Job summary

Prominence Health seeks a seasoned leader to head Health Plan Operations' appeals and grievance functions. You will manage a team responsible for timely, accurate responses to member, provider, and regulator inquiries across multiple lines of business.

The role includes staff development, process improvements, and ensuring regulatory compliance. In this capacity, you will collaborate with operational leaders to enhance outcomes, efficiency, and patient experience, while upholding high standards

Qualifications

• Two years of healthcare management experience with increasing responsibility.
• Two years experience with health plans or employer healthcare benefits programs.
• Two years of experience specific to Grievances and Appeals.
• Four years health plans experience with at least two years in Grievances and Appeals.
• Associate’s degree or equivalent experience.
• Knowledge of State and Federal regulations as they pertain to the health insurance industry.
• Ability to analyze statistical data to identify trends and opportunities for improved service quality.
• Excellent verbal and written communication in English.
• Experience with MS Word, Excel, PowerPoint.

Responsibilities

• Lead the Grievance and Appeals team and ensure timely responses to inquiries, grievances, and appeals across lines of business.
• Oversee staffing, guidance and daily supervision of the Grievance and Appeals team.
• Investigate and resolve member complaints, member grievances and provider disputes.
• Train staff and aid leadership in improving outcomes and operational efficiency.
• Collaborate with operational leaders to identify process improvements and ensure regulatory compliance.

Skills

Healthcare management

Grievances & Appeals

Regulatory compliance

English communication

Problem solving

Education

Associate degree

Tools

Microsoft Word

Excel

PowerPoint

Job description

Responsibilities

Prominence Health is a value-based care organization bridging the gap between affiliated health systems and independent providers, building trust and collaboration between the two. Prominence Health creates value for populations and providers to strengthen integrated partnership, advance market opportunities, and improve outcomes for our patients and members. Founded in 1993, Prominence Health started as a health maintenance organization (HMO) and was acquired by a subsidiary of Universal Health Services, Inc. (UHS) in 2014. Prominence Health serves members, physicians, and health systems across Medicare, Medicare Advantage, Accountable Care Organizations, and commercial payer partnerships. Prominence Health is committed to transforming healthcare delivery by improving health outcomes while controlling costs and enhancing the patient experience.

Learn more at: https://prominence-health.com/

Job Summary: Accountable for leading the Health Plan Operations' appeals and grievance functions. Ensuring that responses to inquiries, grievances, and appeals from members, providers, and regulators are done in a timely, accurate, and appropriate manner across all lines of business. Oversight includes managing the staffing, development, guidance, and daily supervision of the Grievance and Appeals team. Additionally, providing administrative support to investigate and resolve member complaints, member grievances, and provider disputes. Training staff in necessary skills and knowledge base, aiding leadership in enhancing outcomes and operational efficiency. Collaborating with operational leaders to identify process improvement opportunities and ensure regulatory compliance consistently.

Benefit Highlights:

• Loan Forgiveness Program
• Challenging and rewarding work environment
• Competitive Compensation & Generous Paid Time Off
• Excellent Medical, Dental, Vision and Prescription Drug Plans
• 401(K) with company match and discounted stock plan
• SoFi Student Loan Refinancing Program
• Career development opportunities within UHS and its 300+ Subsidiaries! More information is available on our Benefits Guest Website: benefits.uhsguest.com

About Universal Health Services:

One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. During the year, UHS was again recognized as one of the World’s Most Admired Companies by Fortune; and listed in Forbes ranking of America’s Largest Public Companies. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located all over the U.S. States, Washington, D.C., Puerto Rico and the United Kingdom. www.uhs.com

Qualifications

Qualifications and Requirements:

• Two (2) years of healthcare management experience including increasing levels of responsibility.
• Two (2) years experience working with health plans insurance products or employer healthcare benefits programs.
• Two (2) years of experience specific to Grievances and Appeals.
• Four (4) years health plans or health insurance experience required, with a minimum of two (2) years experience specific to Grievances and Appeals.
• Associate’s degree or equivalent experience.
• Knowledge of State and Federal regulations as they pertain to the health insurance industry.
• Previous experience reviewing and analyzing statistical data to identify trends as well as potential problems/opportunities for improved service quality.
• Ability to effectively communicate in English, both verbally and in writing.
• Experience and/or training in computer applications, including Microsoft Word, Excel, and PowerPoint, required.
• Demonstrates ability to work and problem-solve independently --- has taken initiative to research and resolve processing and system issues using available resources and without waiting for direction. Views obstacles encountered as opportunities for improvement and offers ideas and solutions. Knows how to organize people and activities
• Possesses strong/broad understanding of the claims analyst process, medical/dental terminology, and claims processing procedures
• Possesses superior Customer Service skills --- seeks to understand expectations of internal and external customers. Knows which questions to ask and what information to verify to get to the root cause of a problem.
• Possesses excellent verbal and written communication skills --- has demonstrated the ability to effectively and professionally communicate information to both internal and external customers. This includes facilitating meetings, conducting training sessions, organizing and documenting workflows and processes, handling escalated calls, and /or responding to appeals
• Results orientated – understands where tasks and assignments fall into the big picture and organizes and prioritizes accordingly. Diligently follow-ups with Director, peers, other departments, and customers. Gets more out of few resources

EEO Statement

All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws.

We believe that diversity and inclusion among our teammates is critical to our success.