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Role Description

Responsible for overseeing the day-to-day operations of the Grievance and Appeal Specialists, ensuring adherence to department performance standards and operational efficiency. Continuously improve the effectiveness and efficiency of operations in the assigned unit, utilize working knowledge of all G&A areas to ensure that the department is fully compliant with all government regulations. Monitor staff to ensure adherence to all department and company policies. Work with other departments to maximize cooperative relationships; act as an interface with others for excellent customer service and process improvement.

• Manage the day-to-day operations of the staff including new hires.
• Ensure the appropriate staff responds to all member/provider inquiries within the stipulated time frames, thereby ensuring member/provider satisfaction and compliance.
• Have accountability for all performance issues and take appropriate action as warranted.
• Maintain coverage for expedited appeal files on weekends and holidays to ensure EmblemHealth remains compliant as applicable.
• Responsible for identification and root cause analysis of appeal issues, working with applicable business areas to resolve issues.
• Review daily/weekly pend reports to ensure that proper research is being performed and timeframes are met.
• Review quality audits on staff files to effectively evaluate performance and ensure compliance.
• Work with staff as needed to improve performance: monitor attendance and punctuality; complete performance reviews; conduct weekly staff meetings to encourage open communication and build team morale.
• Manage delegate relationships (Beacon, HCP, CMO, EviCore, etc.); collaborate with them to develop workflows, resolve appeal and grievance issues and implement quality improvements.
• Create and implement policies and procedures to ensure that department goals are met using the most efficient and cost-effective measures.
• Participate in creating and implementing continuous process and quality improvement initiatives while fostering a team environment to maintain a high performing unit.
• Conduct root cause analysis: implement process improvements based on findings.
• Prepare for internal/external audits.
• Participate in the recruitment of qualified candidates for all open positions and arrange and monitor the training process for new staff members.
• Monitor staff performance and address any problems during the probationary period.
• Regular attendance is an essential function of the job; perform other duties as assigned or required.

Qualifications

• Bachelor’s Degree
• 4 – 6+ years of relevant, professional work experience
• 1 – 2+ years of managed care experience
• Staff/process management experience
• Additional experience/specialized training may be considered in lieu of educational requirement
• Knowledge of EmblemHealth’s programs, and of the department’s web-based programs
• In-depth knowledge of grievance and appeal processes, federal/state regulations, and contractual/processing guidelines
• Proficient in MS Office (Word, Excel, PowerPoint, Outlook, Teams, etc.)
• Supervisory skills sufficient to direct, motivate, and discipline staff
• Analytical and technical ability to review and analyze procedures and workflow and to make recommendations for streamlining the grievance and appeals process within the functional units of the department
• Strong communication skills (verbal, written, presentation, interpersonal) with all types/levels of audience
• Ability to organize, prioritize, and effectively manage multiple tasks/projects with competing priorities/deadlines
• Proven ability to manage a heavy workload in a dynamic, fast paced environment
• Ability to problem solve, make appropriate decisions, and seek assistance when necessary