Manager Appeals and Grievances
Company: Christus Health
Posted on: September 15, 2020
The Manager of CA&G will oversee the appropriate handling of
member and provider complaints, grievances and appeals for multiple
lines of business including Medicare, Health Exchange, and US
Family Health Plan. The Manager will ensure compliance with
regulatory and accreditation requirements and support company
initiatives and processes related to member and provider
satisfaction and Medicare STARS. The Manager will work closely with
other members of CHRISTUS Health Plan senior management to ensure
high quality, minimal risk and compliant operations.
Provide daily supervision for CAG, including coordination of backup
staffing, cross-training and deployment.
Perform recruiting, hiring, promotion, and performance evaluation
tasks and counsel non-clinical CAG staff. Orient and train new CAG
members. Continually train CAG members concerning grievances,
appeals, and provider disputes/appeals. Coordinate maintenance of
and updates to desktop procedures and manuals for CAG.
Prepare for and represent CAG in all audits, interviews and
compliance meetings including those facilitated by NCQA, CMS, DHA,
OSI, HHSC, TDI.
Oversee the resolution of member complaints, appeals, and
grievances related to quality of care and service, medical
necessity, plan benefits and payments to ensure compliance with
state and federal regulations and NCQA standards.
Coordinate investigation and resolution of complex appeal and
Report data and make recommendations to the appropriate internal
committees and workgroups such as Quality Improvement Committee,
Provider Monitoring, and STARS Program Steering Committee.
Analyze complaint, appeal, and grievance data, develop trend
reports and work with various committees to identify opportunities
for improvement and increase member and provider satisfaction.
Oversee the investigation and resolution of provider
disputes/appeals involving provider terminations, credentialing
denials and claim denials according to state regulations.
Monitor delegated vendor complaint, appeal, and grievance activity
to ensure compliance. Partner with other business areas through the
Delegated Vendor Oversight Committee or other similar groups to
identify issues and develop appropriate action plans to address
Develop, update and maintain corporate policies and procedures to
support new lines of business and reflect changes in contract
language and updates in regulations and standards.
Develop and maintain collaborative relationships with internal and
Design and implement company-wide trainings and in-services to
ensure quicker resolution of member issues and a better
understanding of member and provider appeal rights.
Manage cross-functional employees to meet and exceed service
requirements and functional objectives.
Recruit, develop, motivate and retain a high caliber of team
Coach and lead team to continuously improve operational
Maintain a positive work environment that supports self-direction;
provide a structure to optimize experience, skill, knowledge and
capability of the team.
Reward team members based on contribution and performance.
Manage budget and control expenses while meeting operational,
financial and service requirements.
Perform other duties as assigned
Follow the CHRISTUS Health guidelines related to Health Insurance
Portability and Accountability Act (HIPAA), designed to prevent or
detect unauthorized disclosure of Protected Health Information
Attend weekly and monthly team and department meetings as
Ability to sit for long periods of time.
Ability to organize and prioritize work to meet deadlines.
Ability to work occasional long or irregular hours.
Ability to work flexible work schedule including evenings and
Bachelor's degree from an accredited institution preferred; at
least eight years of experience in the managed care industry is
required; minimum of five years' experience in Appeals is
Highly proficient in applicable business software applications
including PC usage, Microsoft Word, PowerPoint, and Excel.
Preparation of business plans, analyses, and programmatic and
operational reports. Research and program planning methodology.
Strong leadership and problem-solving skills. Excellent oral and
written communication skills including good grammar, voice, and
diction. Ability to read and interpret documents and calculate
figures and amounts. Proficient in MS Office with basic computer
and keyboarding skills. Excellent organizational skills, ability to
prioritize and manage time efficiently and effectively.
Ability to use a computer keyboard and other business machines.
More than 50% of work time is spent in front of a computer
Keywords: Christus Health, Irving , Manager Appeals and Grievances, Executive , Irving, Texas
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