Grievance & Appeals Manager

VNS Health; New York (NY); Hybrid; USD 85,000 - 106,000; Full time

Benefits offered by this job

Referral bonus opportunities

30 days PTO + 9 holidays

Health insurance for you and family

Employer-matched retirement savings

Pre-tax FSAs for healthcare and DEP C

Tuition reimbursement

Career advancement opportunities

Internal mobility and CEU credits

Job summary

VNS Health is seeking a managerial professional to oversee grievance and appeals operations across MLTC, MA, FIDA, and Select Health product lines. The role ensures regulatory compliance and readiness for audits, while coordinating with cross-functional teams to resolve complex cases.

The position emphasizes oversight of data integrity, external reviews, and subcontractor management, with opportunities for professional growth and staff development in a hybrid work environment.

Qualifications

• Bachelor's degree in health/human services, healthcare or business administration or related field; required.
• Master's Degree in public health or health-related field preferred.

Responsibilities

• Manage the intake, investigation and resolution of member grievances and appeals.
• Track grievances and appeals and maintain logs and records.
• Coordinate with Provider Relations, Claims, Medical Director and third parties to resolve appeals and grievances.
• Ensure data collection and reporting systems support CMS/DOH reporting and analysis.
• Supervise subcontractors handling delegated grievance and appeal responsibilities.
• Develop and implement policies, procedures and workflows for grievances and appeals.
• Monitor regulatory trends and recommend improvements.
• Lead staff training and scheduling, and oversee budget and staffing decisions.

Skills

Oral and written communication

Computer literacy

Education

Bachelor's degree in health/healthcare or business administration

Master's degree in public health or health-related field (preferred)

Tools

MS Office

FACETS system

Job description

Overview

Manages the day to day activities for staff handling of grievances and appeals for VNS Health Plans product lines - Managed Long Term Care (MLTC), Medicare Advantage (MA), Fully Integrated Dual Advantage (FIDA) and Select Health. Ensures compliance with state and federal regulatory requirements. Monitors and audits subcontractors who have delegated responsibility for managing grievance and appeals on behalf of the plan to ensure operational and regulatory compliance. Maintains and ensures integrity of case file and data collection systems and prepares data reports and analysis of grievance and appeals for program management and committees, as needed. Works under general direction.

This is a hybrid position.

What We Provide:

• Referral bonus opportunities
• Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays
• Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life Disability
• Employer-matched retirement saving funds
• Personal and financial wellness programs
• Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care
• Generous tuition reimbursement for qualifying degrees
• Opportunities for professional growth and career advancement
• Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities.

What You Will Do:

• Manage the intake, investigation and resolution of member grievances and appeals for VNS Health product lines- Managed Long Term Care (MLTC), Medicare Advantage (MA), Full Integrated Dual Advantage and Select Health to ensure compliance with mandated regulatory processes and timeframes. Maintains readiness for DOH or CMS audit at all times.
• Tracks grievances and appeals that are in process in the department; ensures the integrity of tracking logs and records documenting plan actions and timeframes for each appeal or grievance.
• Communicates with corporate and regional staff at all levels including but not limited to, Provider Relations, Claims, Medical Director, third party administrator, pharmacy benefit manager, to achieve resolution of appeals and grievances.
• Ensures the accuracy and integrity of data collection and reporting systems to support analysis and reporting of grievances and appeals data for operations and for required CMS and DOH reporting. Participates in analyses and reports on grievance and appeal activity for management, committees, and regulatory entities. Analyzes trends and recommends departmental improvements.
• Manages and tracks appeals external to the plan including cases with the CMS independent review entities and NYS Fair Hearings. Supervises investigations and prepares recommended responses to grievances referred to the plan from regulatory entities including but not limited to the Department of Health, CMS and Department of Insurance.
• Manages specialty subcontractors program for delegated grievance and appeal responsibilities. This includes review, analysis and auditing of subcontractors to evaluate compliance with delegated functions and with CMS or DOH regulatory requirements. Recommends and assists in development of audit criteria, conducts audits and prepares audit reports and recommends corrective action as needed; follows-up to ensure that corrective actions have been implemented.
• Prepares and disseminates reports and correspondence to enrollees, providers, regulatory entities and program staff and management as needed. * Assists in the development and implementation of policies, procedures and operational workflows related to grievances and appeals. Recommends and assists in the development of standards and criteria for monitoring compliance with regulatory requirements for MLTC, MA and/or Select Health programs. Monitors and analyzes process flow for timeliness and efficiencies.
• Keeps up to date on the latest regulatory issues/requirements and trends in governing VNS Health Plans products through networking, professional memberships, and select journal reading. Identifies and recommends changes to plan grievance and appeal operations accordingly.
• Identifies, recommends, and develops action plans to improve grievance and appeal workflows and processes, service performance, regulatory compliance and quality standards.
• Serves as a resource on grievances, appeals and external reviews. Identifies and recommends key areas for training and coaching of staff based on departmental monitoring and oversight. Maintains and oversees staff leave schedules, ensures adequate staff coverage for departmental functions year-round, and holiday and weekend coverage.
• Maintains and supervises weekend on-call appeal processes.
• Performs all duties inherent in a managerial role. Ensures effective staff training, evaluates staff performance, provides input for the development of the department budget, and hires, promotes, and terminates staff and recommends salary actions as appropriate.
• Participates in special projects and performs other duties as assigned.

Qualifications

Education: Bachelor's Degree in health/human services, healthcare or business administration or related field, or equivalent work experience. Required Master's Degree in public health or health-related field preferred.

Work Experience: Minimum of five years' progressive professional experience in health care, including a minimum of three years' experience in a Grievance and Appeals or related area such as medical or utilization management in a Managed Care setting. Required Experience in a supervisory role. Preferred. Excellent oral and written communication skills. Required Computer literacy including word processing, spreadsheet applications, and database applications. Required MS Office. Preferred. Experience with FACETS system. Preferred.

Pay Range

USD $85,000.00 - USD $106,300.00 /Yr.

About Us

VNS Health has been committed to meeting the needs of New Yorkers for over 130 years. We're one of the largest nonprofit home- and community-based health care organizations in the country, and today, more than 11,500 team members work together to make a difference in the lives of more than 99,000 patients and members on any given day.