Manager, Appeals & Grievance

Job Summary

Under the general direction of the Director, Appeals & Grievances, the Manager, Appeals and Grievances is responsible for the overall management of the member appeals and grievance processes for their responsible lines of business. The Manager is charged with ensuring compliance with all requirements for each state, regulatory and accreditation body. The Manager will facilitate the involvement of internal and external contributors to the process, ensuring timeliness and thoroughness of case reviews. The Manager will be responsible for the direct supervision of the department Supervisors and other key staff.

This individual will provide technical support, direction, and guidance to ensure staff deliver best in class service and resolution of Appeals and Grievances that meets and exceeds customer expectations. He/she actively leads the recommendation, development, and implementation of short and long-term quality service strategies that improve operations and member satisfaction. This individual is also responsible for departmental management, individual analyst productivity, staff development, staffing, and communication.

Key Responsibilities/Duties – what you will be doing

• Provide leadership and oversight to the complex day to day operations of the Appeals and Grievance Department
• Provide guidance and support to associates through coaching, skills development, and performance feedback to help them reach their full potential and achieve career growth. Set clear expectations for individual and team performance, regularly track progress, and implement corrective actions when necessary to ensure goals are met. Lead by example by demonstrating personal accountability and cultivate a team environment where members take ownership of their responsibilities and contribute to overall team success.
• Create and maintain effective management controls within the company's systems to monitor operational performance, productivity, and adherence to company policies.
• Continuously assess and refine processes to optimize operational efficiency, improve team performance, and maintain compliance with evolving industry standards and regulations
• Work closely with other departments to align team objectives with company-wide goals, ensuring seamless collaboration and effective communication across teams.
• Monitor quality and production standards by the interpretation of data and metrics associated with production turnaround times.
• Partner with the Appeals and Grievances Program Management Team to ensure compliance.
• Collaborate in the overall improvement in business by recommending, designing, and implementing operational changes or enhancements that improve effective and efficient delivery of Appeals and Grievances related information.
• Ensure delivery of optimal customer services by working cross functionally with internal business units and external stakeholders, including physicians, attorneys, and elected officials.
• Other duties and projects as assigned.

Qualifications – what you need to perform the job

EDUCATION, CERTIFICATION AND LICENSURE:

• Required (minimum): BA/BS or equivalent experience in Appeals and Grievances
• Strongly Preferred: BA/BS in health care related field

EXPERIENCE (minimum years required):

• Extensive leadership experience required, including mentoring, and developing associates to support their professional growth and team success.
• A strong ethical background and deep knowledge of compliance is essential. Must have a proven ability to work closely with compliance teams and adhere to regulatory requirements.
• Demonstrated success in creating management controls through systems and reporting to ensure operational efficiency and regulatory compliance.
• Strong personal accountability and a commitment to fostering accountability within the team are essential for success in this role. You will be expected to take ownership of both individual and team performance, ensuring that goals are met and challenges are addressed proactively
• Excellent written, verbal, and presentation skills required. Ability to interact with all levels of personnel, along with knowledge of principles and practices of effective supervision.
• Effective decision-making abilities, strong communication, and organizational skills.
• Work cooperatively as a team member across multiple levels within the organization

SKILL REQUIREMENTS:

• Excellent organizational skills required. Excellent interpersonal/communication skills are essential. Must have computer skills with experience in EXCEL, and WORD. Must have knowledge and demonstrated ability in the use of Windows applications and other comparable systems/applications. Knowledge of basic medical terminology a plus
• Knowledge of basic medical terminology
• Individual must be able to appropriately identify urgent situations and follow the appropriate protocol. Position also requires the ability to manage multiple priorities as well as having the initiative, judgment, and perception to operate within a fast paced, high stress environment. Individual must possess strong organizational, logical reasoning, analytical, and problem-solving skills as well as the attention to detail necessary to act within this complex environment. Individual must also be able to work independently but be able to identify when they should ask for help. The individual should be flexible to respond to changing needs in the Department
• Must be able to work well independently and as a team member. Must be able to work closely with other department staff and must have work coverage plan in place in preparation for scheduled and unscheduled absences, due to importance of position to department’s compliance with various processes
• Requires excellent interpersonal skills and an ability to recognize and understand sensitive customer-oriented issues. Position also requires daily contact, by telephone, with members, providers, and internal departments.

WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS (include special requirements, e.g., lifting, travel):

• Must be able to work under normal office conditions and in a remote capacity from home as required.
• Work requires simultaneous use of a telephone/headset and laptop/keyboard and sitting for extended durations.
• May be required to work additional hours beyond standard work schedule.
• May require occasional weekend hours or evening hours as the needs of the various lines of business dictate.

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.

Compensation & Total Rewards Overview

As part of our comprehensive total rewards program, colleagues are also eligible for variable pay. Eligibility for any bonus, commission, benefits, or any other form of compensation and benefits remains in the Company's sole discretion and may be modified at the Company’s sole discretion, consistent with the law.

Point32Health offers their Colleagues a competitive and comprehensive total rewards package which currently includes:

• Medical, dental and vision coverage

• Retirement plans

• Paid time off

• Employer-paid life and disability insurance with additional buy-up coverage options

• Tuition program

• Well-being benefits

• Full suite of benefits to support career development, individual & family health, and financial health

For more details on our total rewards programs, visit https://www.point32health.org/careers/benefits/

Who We Are

Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities.

Scam alert: Point32Health has recently become aware of job posting scams where unauthorized individuals posing as Point32Health recruiters have placed job advertisements and reached out to potential candidates. These advertisements or individuals may ask the applicant to make a payment. Point32Health would never ask an applicant to make a payment related to a job application or job offer, or to pay for workplace equipment. If you have any concerns about the legitimacy of a job posting or recruiting contact, you may contact TA_operations@point32health.org.

This job has been posted by Ignyte AI on behalf of Point32Health. Ignyte AI is committed to the fundamental principle of equal opportunity and equal treatment for every prospective and current employee. It is the policy of Ignyte AI not to discriminate based on race, color, national or ethnic origin, ancestry, age, religion, creed, disability, sex and gender, sexual orientation, gender identity and/or expression, military or veteran status, or any other characteristic protected under applicable federal, state or local law.

Req ID: R8421