Manager, Appeals and Grievance

GlobalHealth; Oklahoma City (OK); Remote; USD 65,000 - 90,000; Full time

Job summary

GlobalHealth seeks an experienced clinical operations leader to provide daily leadership and ensure adherence to Appeals and Grievances regulatory requirements. You will monitor workflows, coach staff, handle escalations, and report critical metrics while maintaining PHI confidentiality.

Remote work is available with occasional travel; you will collaborate with leadership to drive process improvements and ensure timely resolutions for member appeals and grievances.

Qualifications

• Licensed Practical Nurse (LPN) license required.
• Associates or Bachelors degree in a related field preferred.
• Experience in Appeals & Grievances or call center reporting is ideal.

Responsibilities

• Schedule and balance resources to match demand.
• Monitor and oversee appeals and grievances processes.
• Handle escalations for member issues.
• Manage employee time and attendance.
• Provide coaching and training to A&G team.
• Produce daily critical-metric reports and analyze workflow.

Skills

Prioritization

Detail-oriented

Documentation

HIPAA compliance

Process improvement

Analytical thinking

Education

LPN License

Associate or Bachelor’s degree

Tools

MS Office

Power BI

Mitel

Epic

Job description

WHO WE ARE:GlobalHealth is a fast-growing Medicare Advantage HMO health insurer. We aspire to be the employer of choice in our industry, attracting and retaining a highly talented workforce. Our passion is Genuine Care and Optimal Health for the members we serve. We are unique by providing high touch, high value and a partnership to our members. We go above and beyond to provide personalized, engaging, and responsive services to our members. We work hard to offer affordable health insurance coverage with the benefits people truly want and need. It is our hope to be more than just a health insurance company we want to be long-term partners with our members. We are looking for future employees who exude our core values of taking accountability through ownership, being driven, innovative and who have a passion for continuous learning.WHO YOU ARE:The successful candidate provides daily Clinical leadership and compliance of Appeals and Grievance. Identifying and executing opportunities to promote timeliness and resolution based on regulatory requirements.ESSENTIAL JOB FUNCTIONS:Schedule and balance available resources to match anticipated demandMonitor and oversight of appeals and grievances processHandle escalations for member issuesManage employee time and attendanceProvide coaching and training of A&G teamProvide daily reporting for critical measuresIdentify and execute on opportunities for improvement with workflow and structureManage daily workload for subordinates to ensure contractual and regulatory compliancePerform hiring, coaching and disciplinary actions as requiredServe as primary Clinical representative and advocate for A&G issues and concerns in department leadership meetingsMust maintain confidentiality of business information, including Protected Health Information (PHI), as required by HIPAA and company policy.Performs 1st round Quality of Care reviewsPerforms other duties as assignedEDUCATION:Licensed Practical Nurse (LPN)Associate degree or bachelor’sEXPERIENCE:3 years A&G Clinical operations experience required2 years appeals and grievances required1 year experience with one or more of the following: MS Office (+Power BI a plus), call center management and reporting applications (Mitel) or CRM applications (Epic) requiredFamiliarity with process analytics and continuous improvement methodologies (lean, six-sigma, EOS, TOC) preferredProven history of successful process design and implementation preferredMedicare and/or NCQA experience preferredKNOWLEDGE, SKILLS AND ABILITIES:Exceptional prioritization and task management skillsMust be detail oriented and able to multitask, focusing on multiple cases at a timeStrong documentation skills are essentialAbility to perform essential job functions with high degree of independence, flexibility, and creative problem-solving techniquesAbility to thrive in a results-oriented environmentNaturally pushes to drive tasks to completionWORK ENVIRONMENT:Current work environment is remote; however, some state exclusions apply. Must have access to a reliable and secured internet connection source. Work environment must maintain confidentiality of business information, including Protected Health Information (PHI), as required by HIPAA and company policy. This position will also be required to use reasonable and necessary safeguards to protect GlobalHealth records from unauthorized access, disclosure or damage and will adhere to all GlobalHealth privacy and security policies.TRAVEL:Minimal travel expected (less than 5% in support of corporate initiatives)MANAGER RESPONSIBILITY:Supervises work of others, including planning, assigning, scheduling, and reviewing work, ensuring quality standards. Is responsible for hiring, terminating, training, and developing, reviewing performance and administering corrective action for staff. Plans organizational structure and job content.OTHER DUTIES:Must maintain confidentiality of business information, including Protected Health Information (PHI), as required by HIPAA and company policy.Performs other duties as assigned.This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or witho