Supervisor, Appeals and Grievances (53508)

WHO WE ARE:

GlobalHealth is a fast-growing Medicare Advantage HMO health insurer. We aspire to be the employer of choice in our industry, attracting and retaining a highly talented workforce. Our passion is Genuine Care and Optimal Health for the members we serve. We are unique by providing high touch, high value and a partnership to our members. We go above and beyond to provide personalized, engaging, and responsive services to our members. We work hard to offer affordable health insurance coverage with the benefits people truly want and need. It is our hope to be more than just a health insurance company we want to be long-term partners with our members. We are looking for future employees who exude our core values of taking accountability through ownership, being driven, innovative and who have a passion for continuous learning. 

WHO YOU ARE:

Provides daily leadership and compliance of Appeals and Grievance. Identifying and executing opportunities to promote timeliness and resolution based on regulatory requirements.

ESSENTIAL JOB FUNCTIONS:

• Schedule and balance available resources to match anticipated demand
• Monitor and oversight of appeals and grievances process
• Handle escalations formember issues
• Manage employee time and attendance
• Provide coaching and training ofA&G team
• Provide daily reporting for critical measures
• Identify and execute on opportunities for improvement with workflow and structure
• Manage daily workload for subordinates to ensure contractual and regulatory compliance
• Perform hiring, coaching and disciplinary actions as required
• Serve as primary representative and advocate forA&G issues and concerns in department leadership meetings
• Must maintain confidentiality of business information, including Protected Health Information (PHI), as required by HIPAA and company policy.
• Performs other duties as assigned

EDUCATION:

• High School diploma or GED required
• Associate degree or Bachelor’s preferred

Qualifications

EXPERIENCE:

• 3 years member services and/or customer operations experience required
• 2 years appeals and grievances required
• 1 year experience with one or more of the following: MS Office (+Power BI a plus), call center management and reporting applications (Mitel) or CRM applications (Epic) required
• Familiarity with process analytics and continuous improvement methodologies (lean, six-sigma, EOS, TOC) preferred
• Proven history of successful process design and implementation preferred
• Medicare and/or NCQA experience preferred

KNOWLEDGE, SKILLS AND ABILITIES:

• Exceptional prioritization and task management skills
• Must be detail oriented and able to multitask, focusing on multiple cases at a time
• Strong documentation skills are essential
• Ability to perform essential job functions with high degree of independence, flexibility, and creative problem-solving techniques
• Ability to thrive in a results-oriented environment
• Naturally pushes to drive tasks to completion

WORKING CONDITIONS:

Environment

This job operates in aremote setting. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. This is a largely sedentary role.

TRAVEL:

Minimal travel expected (less than 5% in support of corporate initiatives)

SUPERVISOR RESPONSIBILITY:

OTHER DUTIES:

Add any additional duties not covered in the essential job functions.

• Must maintain confidentiality of business information, including Protected Health Information (PHI), as required by HIPAA and company policy.
• Performs other duties as assigned.

This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.