Manager, Grievance & Appeals

Santa Clara County Health Plan; San Jose (CA); On-site; USD 134,000 - 207,000; Full time

Job summary

Santa Clara County Health Plan is seeking a Manager, Grievance & Appeals to lead the development and oversight of all grievance and appeal activities for members and providers. The role ensures regulatory compliance and accurate reporting while representing the plan with regulators, providers, and auditors.

The position oversees day-to-day operations of the G&A team, drives process improvements, manages audits, and partners with cross-functional teams to enhance member experience and operational

Qualifications

• Four-year degree in General Business, Law, Social Sciences or Health Care Administration.
• Minimum two years management experience including direct supervisory experience of multiple staff.
• Minimum three years of health plan operations experience, with demonstrated knowledge of health plan operations and the interactions between appeals and grievances, customer service, utilization management, claims and provider relations.
• Knowledge of Medicare and Medicaid/Medi-Cal requirements.
• Process/systems thinker with attention to detail and the ability to develop and improve cross-functional processes.
• Time management skills with the flexibility to constantly manage and shift priorities.
• Working knowledge and the ability to efficiently operate all applicable computer software including applications such as Outlook, Word and Excel.
• Excellent customer service skills via phone, email, written communications and in-person.
• Effective oral and written communication skills.
• Research and documentation skills required to obtain appropriate information required to resolve cases.
• Ability to form trusted relationships with staff, regulators and other external parties involved in case resolution.

Responsibilities

• Read, interpret and implement all regulatory guidance related to handling of appeals and grievances.
• Demonstrate a solid understanding of the appeals and grievance processes and reporting requirements.
• Establish and document processes, policies, procedures and workflows to support compliant handling.
• Manage all grievance and appeals related reports ensuring accuracy and timeliness of submissions.
• Prepare case files and represent SCFHP in State Hearings or other escalated cases.
• Act as the subject matter expert and initial contact for complex grievance and appeals cases.
• Lead and facilitate department and cross-functional meetings to review cases.
• Identify grievance and appeal trends and conduct root-cause analysis for interventions.

Skills

Regulatory knowledge

People management

Process improvement

Excellent customer service

Regulatory reporting

Analytical thinking

Communication skills

Regulatory interpretation

Education

Bachelor's degree in General Business, Law, Social Sciences or Health Care Administration

Tools

Outlook

Word

Excel

Job description

Manager, Grievance & Appeals

Salary Range: $133,757 - $207,324
The expected pay range is based on many factors, such as experience, education, and the market. The range is subject to change.

FLSA Status:Exempt
Department:Grievance & Appeals
Reports To:Director, Operations

GENERAL DESCRIPTION OF POSITION

The Manager, Grievance & Appeals is the primary point person responsible for the development and management of all grievance and appeal related activities and for providing a positive and professional experience for members and providers going through grievance or appeals processes. As the go-to person for grievances and appeals, this position interprets guidance from regulators, implements processes to ensure compliance, oversees the day-to-day operations of the grievance and appeals staff and represents the plan externally with providers, delegates and regulators in scheduled and ad hoc meetings, joint operating committee meetings, hearings and audits.

ESSENTIAL DUTIES AND RESPONSIBILITIES

To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below.

1. Read, interpret and implement all regulatory guidance related to the handling of appeals and grievances, including the Medicare Managed Care Manual, State and Federal contracts , APLs,DPLs and other memos that provide direction.
2. Demonstrate a solid understanding of the appeals and grievance processes, including all regulatory and reporting requirements.
3. Establish and document processes, policies, procedures and workflows to support compliant and timely handling of appeals and grievances.
4. Create and implement any necessary corrective action plans to bring areas of non-compliance into compliance.
5. Manage all grievance and appeals related reports ensuring accuracy and timeliness of submissions.
6. Prepare case files and represent SCFHP in State Hearings or other escalated types of cases, including development of the Statement of Position and Independent Review Entity (IRE) case narratives.
7. Act as the subject matter expert and initial point of contact for complex and escalated grievance and appeals cases for the department staff.
8. Schedule regular department and cross functional meetings with contributing departments to review grievance and appeal cases and facilitate regular communications.
9. Lead and facilitate active participation and guidance from the attendees of the Grievance and Appeals Workgroup.
10. Lead efforts to identify grievance and appeal case trends and conduct root cause analysis for the development of interventions to improve SCFHP operations and the customer experience for members and providers.
11. Manage internal and external audits of grievance and appeals.
12. Demonstrate competency to utilize existing systems and represent the appeals and grievance team in establishing or implementing new systems related to appeals and grievances.
13. Develop, document, and train staff on appeals and grievance categorization, systems, processes, policies, procedures, and workflows required to manage the appeals and grievance processes throughout the organization.
14. Direct and manage appeals and grievance staff in order to adhere to accurate processing and resolution of appeals and grievances. This includes demonstrating the flexibility and judgment required to constantly re-shift prioritization of cases to accommodate timely handling and resolution.
15. Develop and manage reporting to monitor key performance indicators, identify trends, conduct root cause analysis, report to appropriate committees, and adhere to regulatory reporting requirements.
16. Communicate effectively both internally and externally in order to continuously improve communication and quality. Work cross functionally, including attendance at organizational and departmental meetings to train and address issues that may prevent the appropriate identification of and resolution of appeals or grievances.
17. Perform other related duties as required or assigned.

SUPERVISORY/MANAGEMENT RESPONSIBILITIES

Carries out supervisory responsibilities in accordance with the organization's policies, procedures, applicable regulations and laws. Responsibilities include:

1. Managing the grievance and appeals team with regard to work priorities, projects, reports, and maintenance of the G & A system(s), including training, promotion, enforcement and auditing of internal procedures, controls and problems; motivating employees to achieve peak productivity, performance and quality. Monitoring work schedules and time off requests to ensure that adequate coverage is available for internal staff during regular business hours.
2. Recruiting, interviewing, and hiring.
3. Developing a high performing department culture and staff. This includes setting the standard for staff and motivating employees to maximize organizational goals and objectives.
4. Effectively assimilating, training and mentoring staff and (when appropriate), cross training existing staff and initiating retraining. This includes coaching to help increase skills, knowledge and (if applicable) improve performance.
5. Setting goals and planning, assigning, and directing work consistent with said goals. This includes responding to employees' needs, ensuring they have the necessary resources to do their work.
6. Appraising performance, rewarding and disciplining employees, addressing complaints and resolving issues. This includes providing regular and effective feedback to employees and completing timely and objective performance reviews.

REQUIREMENTS - Required (R) Desired (D)

The requirements listed below are representative of the knowledge, skill, and/or ability required or desired.

1. Four-year degree in General Business, Law, Social Sciences or Health Care Administration, or related experience. (R)
2. Minimum two years management experience including direct supervisory experience of multiple staff, responsibility for hiring and performance management. (R)
3. Minimum three years of health plan operations experience, with demonstrated knowledge of health plan operations and the interactions between appeals and grievances, customer service, utilization management, claims and provider relations. (R)
4. Two years of experience working in grievances and/or appeals (including medical and pharmacy), or a closely related area of health plan operations. (R)
5. Knowledge of Medicare and Medicaid/Medi-Cal requirements. (R)
6. Process/systems thinker with attention to detail and the ability to develop and improve cross-functional processes. (R)
7. Time management skills with the flexibility to constantly manage and shift priorities. (R)
8. Working knowledge and the ability to efficiently operate all applicable computer software including applications such as Outlook, Word and Excel. (R)
9. Excellent customer service skills via phone, email, written communications and in-person. (R)
10. Effective oral and written communication skills. (R)
11. Research and documentation skills required to obtain appropriate information required to resolve cases. (R)
12. Ability to form trusted relationships with staff, co-workers, regulators and other external parties involved in case resolution. Strong people management skills to manage department staff. (R)
13. Ability to use a keyboard with moderate speed and a high level of accuracy. (R)
14. Excellent communication skills including the ability to express oneself clearly and concisely when interacting with SCFHP internal and external stakeholders over the telephone, in person or in writing and the ability to remain calm and de-escalate tense situations. (R)
15. Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R)
16. Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R)
17. Ability to maintain confidentiality. (R)
18. Ability to comply with all SCFHP policies and procedures. (R)
19. Maintenance of a valid California driver's license and acceptable driving record, in order to drive to and from off-site meetings or events, or the ability to use other means of transportation to attend off-site meetings or events. (R)
20. Ability to perform the job safely and with respect to others, to property and to individual safety. (R)

WORKING CONDITIONS

Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications.

PHYSICAL REQUIREMENTS

Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation:

1. Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R)
2. Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R)
3. Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R)
4. Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R)
5. Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R)
6. Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R)

ENVIRONMENTAL CONDITIONS

General office conditions. May be exposed to moderate noise levels.

EOE