General Summary:
The Manager, Appeals and Grievance plans, directs, evaluates, and coordinates the activities associated with appeals and grievance operations, as it relates to key HAP initiatives and service excellence. Principally, the manager is accountable for oversight, auditing and real-time monitoring of complaints, grievances and, appeals for various products but will support their peer manager when necessary for other product lines to ensure complete, accurate and timely processing, in accordance with regulatory mandates including NCQA, Department of Labor (DOL) and Center for Medicare/Medicaid Services (CMS). The Manager assists the Clinical Director, Appeals & Grievance to analyze, maintain and report on all grievance and appeal related information to the Department of Financial Services (DIFS), CMS, Member Services Committee of the HAP Board of Directors, CEO and COO of HAP and the Vice President of Consumer Operations. Maintains a formal history of appeals and grievances to utilize for process improvements, forecasting and planning for people, resources, and technology. Develops and implements an on-going training plan for all staff handling complaints, grievances and appeals and ensures staff is aware of changing regulatory requirements and internal/external compliance rules.
Principal Duties and Responsibilities:
- Provide daily direction, monitoring and oversight for Appeal and Grievance staff, which includes the appropriate coaching and development, planning, staffing and coordination of activities as they pertain to divisional and corporate goals, strategies, and objectives.
- Provide daily strategic direction, planning and forecasting for the Appeal and Grievance leadership team to ensure departmental, corporate and system initiatives are defined, implemented, tracked, monitored, and achieved.
- Determine training (including just-in-time training based on monitoring results), policy, procedure, and benefit needs related to timely and accurate processing of all case types.
- Ensures compliance within the individual regulatory mandates for every product line (NCQA, DIFS, DOL, HIPAA, MDHHS and CMS) and operate within HAP defined business and compliance processes, including timely completion of cases.
- Supply necessary internal control oversight information regarding system changes affecting the Appeals & Grievance processing to ensure proper system testing, system documentation, user training, etc., is performed prior to implementation.
- Develop and review department and corporate operational policies and procedures in accordance with DIFS, NCQA, DOL, MDHHS and CMS regulations and within departmental standards. Lead team to ensure workflow is continuous, performance standards are met, and staff operates within the regulatory mandates such as CMS, NCQA, DIFS, DOL and HIPAA with respect to the various product lines.
- Partner to collect and submit the corporate grievance and appeal reports for Medicare Part B, C & D that must be electronically sent to CMS for Data Validation
- Assist in preparation all appeal and grievance data for regulatory agency reviews (NCQA, CMS, DIFS, MDHHS and Medicare 5 Star). Attend regulatory agency interview meetings during their review of the appeal and grievance data to answer questions and explain monitoring processes to the various interviewers from these agencies.
- Support achievement of HAP and Department specific KPIs to measure compliance and operational performance. Support in identifying key areas of process improvement activities to help achieve of HAP’s Medicare 5-Star metric goals as it relates to appeal, grievance, and complaints.
- Participate in Medicare Programs workgroups to ensure successful achievement of corporate objectives and regulatory compliance. Participate in Medicare Program conference calls with CMS to ensure changes are understood and communicated effectively to appropriate staff.
- Analyze complaint, appeal, and grievance data to identify impacting trends, perform root cause analyst and recommend customer service and process improvements. Coordinate preparation of annual appeal and grievance report. Present report to the Member Services Committee of the HAP Board of Directors annually.
- Develop skills and competencies of indirect reports to maximize employee engagement, increase productivity and create an environment of teamwork and commitment; coach and counsel people to exceed performance levels through professionalism, positive relations, and timeliness in all customer contacts.
- Other duties delegated or assigned by Clinical Director, Appeals and Grievance.
Education/Experience Required:
- Bachelor’s Degree required, or an additional four (4) years of related or relevant experience may be considered in lieu of education requirement.
- Minimum of three (3) years managed care experience with emphasis on program management and improvement in health care operations
- Strong experience working in the managed care industry, including familiarity with performance/quality improvement, business operations, physician organizations, medical management, and quality areas.
Skills Required:
Must meet or exceed core customer service responsibilities, standards and behaviors as outlined in the HFHS’ Customer Service Policy and summarized below:
Communication Ownership
Understanding Motivation
Sensitivity Excellence
Teamwork Respect
Must practice the customer skills as provided through on-going training and in-services.
Must possess the following personal qualities:
Be self-directed
Be flexible and committed to the team concept
Demonstrate teamwork, initiative, and willingness to learn
Be open to new learning experiences
Accepts and respects diversity without judgment
Demonstrates customer service values
Physical Demands/Working Conditions:
Normal office environment with minimal exposure to noise, dust, or extreme temperatures.