Senior Manager of Grievance and Appeals

This position leads the development and administration of the Grievance and Appeals Unit (GAU) including oversight of the process of advocating for member rights within the organization, assuring grievance and appeal trends are reported to and addressed within the appropriate quality improvement committee(s). The Senior Manager leads and supervises the Grievance and Appeals Unit (GAU) and leads all aspects of the organization of work and workflow so that performance standards and procedures for grievances, complaints and appeals investigation and resolution are compliant with organizational and regulatory requirements. The Senior Manager is responsible for the oversight of the grievances, complaints, and appeals processes across the company for providers and members. The Senior Manager ensures all processes meet contractual and regulatory requirements across all product lines (Medicaid, Commercial, and Medicare-Medicaid Plan), including the reporting requirements relevant to grievances, appeals and complaints. This role leads in the oversight of any delegated activities related to grievances and appeals and ensures comprehensive oversight and monitoring of the delegate(s). The Senior Manager is responsible for gathering and analyzing data related to the performance of the department and company and identifying process improvement opportunities. Additionally, the Senior Manager is responsible for internal, external, and ad-hoc reporting as required by regulatory bodies.

Duties and Responsibilities:

Responsibilities include, but are not limited to the following:

• Serves as the subject matter expert and lead on functional deliverables ensuring optimal efficiency as it relates to Grievances and Appeals.
• Leads to ensure operational excellence.
• Supervise daily operations related to grievances, complaints, and appeals to ensure department service key performance measures and regulatory requirements are achieved.
• Collaborate with internal departments to ensure compliance with regulatory requirements related to external review process for all products including serving as primary contact for the external review agent/s.
• Engage in ongoing performance management of staff including coaching, mentoring, development, training and succession planning to include hiring and termination decisions.
• Provide leadership and departmental monitoring to assure compliance and commitment to excellence with local, state and federal regulations, such as, NCQA, EOHHS, CMS, and OHIC.
• Supervise implementation of departmental regulatory requirements / changes and ensure departmental Policies and Procedures are up to date.
• Monitor and implement processes related to grievance, complaints, and appeals to ensure compliance across the company and within the GAU.
• Collaborate with Medical Director and/or Utilization Management Staff on sensitive or complex appeals.
• Supervise timely and compliant submission of regulatory reports.
• Continually evaluate operations and identify process improvement opportunities. Identify irregular trends with member and provider grievances, complaints, and appeals; collaborate with other areas as appropriate to identify root causes and appropriate steps for resolution.
• Develop and continuously monitor departmental workflows to ensure maximum level of efficiency and compliance.
• Monitor and work with member/provider-facing departments to ensure that grievances, complaints, and appeals are appropriately triaged and reported to the GAU for investigation and resolution.
• Proactively keep the Director of QI and GAU informed of the team's performance, projects, and issues.
• Regularly represent the department's objectives through oral and written presentations to senior management, staff, internal and external customers.
• Develop, deliver and/or coordinate the organizational grievances, complaints, and appeals training to other areas as needed.
• Attend meetings/serve as committee member as required.
• Ensure GAU follows all relevant contractual requirements, including state and federal regulations, accreditation, compliance, audit, and privacy guidelines.
• Successfully leads the GAU through regulatory audits for all product lines (Medicaid, Commercial and Medicare-Medicaid Plan).
• Monitor Medicaid and Medicare processes to ensure that all regulatory requirements are followed.
• Primary departmental representative during regulatory audits of grievances, complaints, and appeals.
• Develop and continuously monitor the budget for Grievances and Appeals and provide effective and efficient budget management that assures the best utilization of resources.
• Serves as the business owner and provides oversight of FDR vendor relationships for any delegated activities related to the GAU.
• Responsible for coordinating with departments to develop seamless end to end processes across all levels of the organization as it relates to grievances, complaints, and appeals.
• Other duties as assigned.
• Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood's Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents.

Qualifications

Required:

• Bachelor's degree in health care administration or related field, or an equivalent combination of education and experience as outlined below
• Five (5) or more years experience in managed care or health plan operations
• Five (5) or more years of leadership and supervisory experience
• Expertise and deep knowledge and experience in Medicare and Medicaid requirements, Center for Medicare and Medicaid Service (CMS) regulations, and the National Committee for Quality Assurance (NCQA) accreditation
• Complaint resolution experience with a strong Customer Service focus
• Experience in data collection, presentation and action plans including presenting at an audit setting such as CMS and NCQ
• Demonstrated ability to effectively prioritize and implement tasks and special projects
• Demonstrated ability to work both independently and as a team member
• Ability to influence without authority
• Intermediate to Advanced skills in Microsoft Office (Word, Excel, PowerPoint, Outlook)
• Strong verbal and written communications skills

Preferred:

• Registered Nurse with active RN license in the state of Rhode Island
• Masters' Degree in Healthcare Administration or related field
• Related Professional Training and/or Certifications
• Experience with Behavioral Health, Pharmacy, and Utilization Management
• Experience and expertise in grievance and appeals processes and requirements
• Experience in medical review criteria tools (Interqual strongly preferred)

Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.