Job Summary:
The Manager, Grievance and Appeals is responsible for oversight of the Grievance, Appeal, IRE/IRO and State Hearing teams within CareSource. This position focuses specifically on Marketplace (Healthcare Exchange) LOB.
Essential Functions:
- Provide leadership and direction to staff to ensure the goals and standards of the department and CareSource are successfully achieved
- Manage staff to ensure timely and accurate completion of tasks and issues are accomplished
- Oversee and monitor processes to ensure department is meeting all regulatory requirements and accreditation standards
- Oversee and ensure grievances and appeals are resolved and reported appropriately
- Oversee, analyze and provide feedback to all areas that submit grievances and appeals
- Develop, implement and execute grievances and appeals training to business areas as needed
- Analyze and evaluate operations and identify process improvement
- Identify irregular trends with grievances and appeals; work with other areas as appropriate to identify root causes and appropriate steps for resolution
- Monitor trends and regulatory changes for impact to the department
- Report data to appropriate committees with CareSource
- Oversee, develop and execute the grievances and appeals process for new product lines
- Review and interpret regulatory requirements and ensure business policies and processes are in compliance
- Lead initiatives to track and trend grievances and appeals data in order to drive process improvements
- Develop a culture of accountability and flexibility within the team to support the organizational mission and vision
- Perform any other job duties as requested
Education and Experience:
- Bachelor’s degree or equivalent years of relevant work experience is required
- Prior experience in the healthcare industry is preferred
- Minimum of three (3) years of management experience is preferred
- Minimum of four (4) years of grievance and appeals experience is preferred
Competencies, Knowledge and Skills:
- Proficient in Microsoft Office Suite to include Word, Excel and PowerPoint
- Basic experience with ACD systems
- Basic experience with Call Management Systems
- Excellent written and verbal communication skills
- Strong interpersonal skills, high level of professionalism and a collaborative management style
- Effective problem solving skills with attention to detail
- Effective listening and critical thinking skills
- Ability to work independently and within a team environment
- Ability to develop, prioritize and accomplish goals
- Strategic management skills
- Familiarity of the healthcare field with knowledge of Medicaid and Medicare
- Ability to work in a fast-paced and constantly changing environment
Licensure and Certification:
Working Conditions:
- General office environment; may be required to sit or stand for extended periods of time
Compensation Range:
$79,800.00 - $127,600.00
CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type (hourly/salary):
Salary
Organization Level Competencies
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer, including disability and veteran status. We are committed to a diverse and inclusive work environment.
