Manager, Grievance and Appeals, RN

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

Job summary

VNS Health seeks a dedicated Manager, Grievance and Appeals (RN) to oversee grievance processes and ensure compliance with healthcare regulations. This role offers a mostly remote environment and opportunities for professional growth while making a significant impact on member experiences.

Benefits

Referral bonus opportunities

Generous paid time off

Health insurance

Employer-matched retirement savings

Tuition reimbursement

Qualifications

• Current RN license in New York State required.
• Minimum of five years’ progressive healthcare experience.

Responsibilities

• Oversee clinical appeals review processes.
• Manage intake and resolution of member grievances.
• Develop reports for stakeholders and regulatory entities.

Skills

Communication

Computer literacy

Education

Associate's Degree in Nursing

Bachelor's Degree

Tools

MS Office

FACETS

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:

• 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.
• Ensure Compliance: Stay ahead of the game by ensuring compliance with state and federal regulations. Your expertise will help us navigate the ever-evolving healthcare landscape.
• Monitor and Audit: Collaborate with subcontractors, ensuring they meet our high standards for operational and regulatory compliance in managing grievances and appeals on our behalf.
• Data-Driven Decisions: Maintain the integrity of our case files and data collection systems. Prepare insightful reports and analyses that inform program management and committee decisions.
• Work Flexibly: Enjoy a mostly remote work environment with just one day a month in the office, allowing you to maintain a 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 plan for you and your loved ones, including Medical, Dental, Vision, Life, and Disability coverage
• Employer-matched retirement savings 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, CEU credits, and other development opportunities

What You Will Do

• Oversee the clinical appeals review processes within the Appeals & Grievances Department.
• Manage the intake, investigation, and resolution of member grievances and appeals for specified VNS Health Plans product lines, ensuring compliance with regulatory timeframes and readiness for audits.
• Ensure regulatory compliance and timely processing of appeals and grievances, including incidents, quality of care concerns, and clinical reviews.
• Serve as a subject matter expert to internal departments and delegated vendors, ensuring education and compliance with appeals and grievance regulations.
• Streamline processes to improve staff knowledge, engagement, and member experience.
• Track and document grievances and appeals, maintaining data integrity.
• Coordinate with various internal and external stakeholders to resolve issues.
• Analyze data and reports, identify trends, and recommend improvements.
• Manage external appeals cases, investigations, and responses to regulatory inquiries.
• Supervise subcontractors involved in delegated grievance and appeal responsibilities, including audits and corrective actions.
• Develop reports and correspondence for stakeholders and regulatory entities.
• Assist in policy development, compliance monitoring, and workflow analysis.
• Stay updated on regulatory issues and trends, recommending operational adjustments.
• Identify areas for process improvement and staff training.
• Maintain staff schedules, oversee leave and on-call processes, and ensure adequate coverage.
• Perform managerial duties such as staff training, performance evaluations, and hiring.
• Participate in special projects and perform other duties as assigned.

Qualifications

Licenses and Certifications:

• Current RN license in New York State required

Education:

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

Work Experience:

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

Pay Range

USD $109,900.00 - USD $146,500.00 /Yr.

About Us

VNS Health is one of the nation’s largest nonprofit home and community-based health care organizations, committed to providing compassionate, comprehensive care for over 130 years. We serve more than 43,000 neighbors daily through a wide range of health services and innovative solutions, powered by advanced data analytics to improve health outcomes in New York and beyond.