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Manager Appeals and Grievances

Company: Christus Health
Location: Irving
Posted on: September 15, 2020

Job Description:

Description
Summary:

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 grievance issues.
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 deficiencies.
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 external customers.
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 members.
Coach and lead team to continuously improve operational performance.
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 (PHI).
Attend weekly and monthly team and department meetings as appropriate.
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 weekends.

Requirements:

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 preferred.

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. Project Management.

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 monitor.

Keywords: Christus Health, Irving , Manager Appeals and Grievances, Executive , Irving, Texas

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