Manager, Grievance and Appeals, RN

VNS Health; New York (NY); Hybrid; USD 109,000 - 147,000; Full time

Job summary

An established industry player is seeking a dedicated Manager for Grievance and Appeals to lead operations in navigating the complexities of healthcare. This role offers the chance to make a significant impact by ensuring compliance with regulations, managing staff interactions, and improving services for members. With a mostly remote work environment, you will oversee the grievance and appeals processes, collaborate with subcontractors, and utilize data-driven decisions to enhance member experiences. Join a team committed to making a difference in the lives of individuals through compassionate care and innovative solutions.

Benefits

30 days of paid time off

Health insurance

Employer-matched retirement savings

Tuition reimbursement

Referral bonus opportunities

Qualifications

• 5+ years of progressive healthcare experience, including grievance and appeals.
• Registered Nurse license in New York State is required.

Responsibilities

• Manage clinical appeals review processes and ensure compliance.
• Oversee the resolution of member grievances and appeals.

Skills

Healthcare Management

Regulatory Compliance

Data Analysis

Communication Skills

Supervisory Skills

Education

Associate's Degree in Nursing

Bachelor's Degree in Nursing

Tools

MS Office

FACETS system

Job description

Overview

Are you passionate about making a difference in the lives of individuals navigating the complexities of healthcare? VNS Health Plans is seeking a dedicated Manager, Grievance and Appeals (RN) to lead the daily operations of our grievance and appeals processes. You will play a crucial role in overseeing staff interactions and ensuring that our members' voices are heard, their concerns are addressed, and that we continuously improve our services.

This is an exciting opportunity to:

1. Lead with Purpose: Manage day-to-day activities for staff handling grievances and appeals across our Managed Long Term Care (MLTC), Medicare Advantage (MA), or Select Health product lines.
2. Ensure Compliance: Stay ahead of the game by ensuring compliance with state and federal regulations. Your expertise will help us navigate the healthcare landscape.
3. Monitor and Audit: Collaborate with subcontractors, ensuring they meet our high standards for operational and regulatory compliance in managing grievances and appeals.
4. Data-Driven Decisions: Maintain the integrity of our case files and data collection systems. Prepare reports and analyses that inform management and committee decisions.
5. Work Flexibly: Enjoy a mostly remote work environment with one day a month in the office, supporting work-life balance while contributing to meaningful change.

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 for you and your loved ones, including Medical, Dental, Vision, Life, and Disability
• Employer-matched retirement savings funds
• Personal and financial wellness programs
• Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care
• Tuition reimbursement for qualifying degrees
• Opportunities for professional growth and career advancement

What You Will Do

• Oversee and manage clinical appeals review processes within Appeals & Grievances Department.
• Manage the intake, investigation, and resolution of member grievances and appeals for specified VNS Health Plans product lines, ensuring compliance with regulations and readiness for audits.
• Ensure regulatory compliance and timely processing of appeals and grievances related to Medicare and Medicaid, including incidents, quality concerns, and clinical reviews.
• Act as a subject matter expert to internal departments and vendors, ensuring education and compliance with appeals and grievance regulations.
• Work with the team to streamline processes, improve staff knowledge, and enhance member experience.
• Track and ensure the integrity of grievance and appeal records, and communicate with various stakeholders to resolve issues.
• Ensure data accuracy for reporting and analysis, supporting regulatory and management needs.
• Manage external appeals, investigations, and responses to regulatory entities.
• Supervise subcontractors involved in delegated grievance and appeal responsibilities, including audits and corrective actions.
• Prepare reports and correspondence for stakeholders and regulatory bodies.
• Assist in policy development, monitoring compliance, and process improvement initiatives.
• Stay updated on regulatory issues and trends, recommending operational adjustments accordingly.
• Identify areas for training, coaching, and process enhancement, maintaining staff schedules and coverage.
• Maintain and supervise weekend on-call appeal processes.
• Perform managerial duties including staff training, performance evaluation, budgeting, hiring, and termination.
• Participate in special projects and other duties as assigned.

Qualifications

Licenses and Certifications:

• Registered Nurse license and current registration in New York State required

Education:

• Associate's Degree in Nursing required
• Bachelor's Degree in Nursing preferred

Work Experience:

• Minimum of five years' progressive healthcare experience, including at least three years in grievance and appeals or related areas in Managed Care required
• Supervisory experience preferred
• Excellent communication skills required
• Computer literacy essential, MS Office preferred; FACETS system experience is a plus

Compensation

$109,900.00 - $146,500.00 annually

About Us

VNS Health is one of the nation's largest nonprofit home and community-based health care organizations, with over 130 years of experience. We are committed to health and well-being, helping people live, age, and heal in their own homes. Our team of more than 10,000 delivers compassionate care and innovative solutions to over 43,000 individuals daily, supported by data analytics and a comprehensive range of health services in New York and beyond.