Manager, Appeals & Grievances – Medicaid Care Compliance

Amida Care Inc.; New York (NY); Vor Ort; USD 71.000 - 89.000; Vollzeit

Zusammenfassung

Amida Care Inc. in New York seeks a Manager, Appeals and Grievances to lead day-to-day operations of complaints and appeals, ensuring timely investigations and regulatory compliance.

The role supervises the Appeals and Grievances Associate, analyzes trends, and drives process improvements to enhance member experience. A Bachelor's in health administration or business is required; Medicaid experience is preferred.

Qualifikationen

• Minimum four (4) years of complaints and grievances experience in a Medicaid environment.
• Significant experience with A&G tracking software required.
• Ability to collect and analyze complaint data from various data sources.
• Intermediate level of proficiency with Microsoft Word and Excel.
• Must be able to work independently and with all levels of management staff under time pressure.
• Extensive knowledge of Medicaid regulations is preferred.
• Minimum of two to three (2-3) years of supervisory or management experience preferred
• Excellent verbal, written and interpersonal skills; bilingual in English and Spanish preferred.

Aufgaben

• Handle, investigate, and resolve all complaints received from members, providers, state and federal regulators, and other sources, ensuring appropriate follow-up, documentation, escalation, and timely resolution in accordance with federal and state regulatory requirements.
• Manage the daily activities of the Appeals and Grievances Associate, ensuring all complaints are accurately received, categorized, investigated, documented, and resolved within applicable regulatory and organizational timeframes.
• Work across Amida Care and delegated entities to ensure all complaints and inquiries are handled through appropriate escalation processes in order to meet both compliance and member needs.
• Serve as the A&G trainer for all departments regarding complaint identification, management, and complaint documentation.
• Monitor complaint trends, identifying recurring issues, provider concerns, operational deficiencies, and barriers affecting the member experience for reporting and to present in organizational meetings.
• Conduct root-cause analysis and develop recommendations to address recurring complaints and reduce preventable complaints and complaints appeals.
• Responsible for conducting Quality Assurance (QA) reviews for the complaint process to ensure accurate documentation and timeliness.
• Create data reports for management for complaints and complaints appeal as needed.
• Participate in Call Calibrations for Delegated Entities scheduled by the Quality Team for the Member Service Department.
• As requested, attend meetings to represent the Appeals and Grievances department.
• Work with Director on special projects for process improvement for the Member Experience, Member Services, A&G and Growth departments as requested.

Kenntnisse

Data analysis

Regulatory knowledge

Communication skills

Project coordination

Bilingual English/Spanish

Ausbildung

Bachelor's degree in health administration or Business

Tools

A&G tracking software

Microsoft Excel

Salesforce

Jobbeschreibung

Amida Care Inc. in New York seeks a Manager, Appeals and Grievances to lead day-to-day operations of complaints and appeals, ensuring timely investigations and regulatory compliance.

The role supervises the Appeals and Grievances Associate, analyzes trends, and drives process improvements to enhance member experience. A Bachelor's in health administration or business is required; Medicaid experience is preferred.