Grievance and Appeals Manager

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The Company:

AlohaCare is a local, non-profit health plan serving the Medicaid and Medicare dual eligible population. We provide comprehensive managed care to qualifying health plan members through well-established partnerships with quality health care providers and community-governed health centers. Our mission is to serve individuals and communities in the true spirit of aloha by ensuring and advocating access to quality health care for all. This is accomplished with emphasis on prevention and primary care through community health centers that founded us and continue to guide us as well as with others that share our commitment. As Hawaii’s third-largest health plan, AlohaCare offers comprehensive prevention, primary and specialty care coverage in order to successfully build a healthy Hawaii.

The Culture:

AlohaCare employees share a passion for helping Hawaii’s most underserved communities. This passion for helping and caring for others is internalized and applied to our employees through a supportive and positive work environment, healthy work/life balance, continuous communication and a generous benefits package.

AlohaCare’s leadership empowers and engages its employees through frequent diversity, recognition, community, and educational events and programs. AlohaCare has a strong commitment to support Hawaii’s families and reinforces a healthy work/home balance for its employees. Because AlohaCare values honesty, respect and trust with both our internal and external customers, we encourage open-door, two-way communication through daily interactions, employee events and quarterly all-staff meetings. AlohaCare’s comprehensive benefits package includes low cost medical, dental, drug and vision insurance, PTO program, 401k employer contribution, referral bonus and pretax transportation and parking program.

These employee-focused efforts contribute to a friendly, team-oriented culture which is positively reflected into the communities we serve.

Position Summary:
Responsible for management oversight of Grievances and Appeals Department to investigate, resolve, and respond to client/provider grievances/appeals and ensure compliance with regulatory requirements. Ensures that response to complaints, grievances and appeals is done in a timely, professional, customer-focused manner, and is well-documented. Ensures that tracking and reporting is performed per QUEST Integration, CMS, NCQA, and other accreditation and regulatory requirements and AlohaCare standards. Maintains and coordinates staff activities to achieve departmental and corporate goals to improve service to customers/providers and assures regulatory compliance. Addresses both internal/external customer/provider needs and concerns related to team activities. Ensures programs support overall Quality Improvement Program and meet regulatory compliance/accreditation and the company standards. Hires, trains, coaches, counsels, evaluates performance of direct reports, and other duties as assigned.

Primary duties may include, but are not limited to:
• Develops and maintains program definition, workflows, working documents and tools, Service Level Agreements, Policies and Procedures, reports, trainings, and other work product as needed.
• Communicates program status to Director of Quality, and other Executives as needed
• Reports to internal and external QI meetings; Works with regulatory agencies to secure approvals as needed. Prepares all Grievance & Appeals reports, as required by QUEST Integration, CMS, or other regulatory agencies per format and timeframes specified. Report drafts are prepared in advance with sufficient time for internal management review
• Provides leadership and direction to multiple staff in the G&A division.
• Hires, trains, coaches, counsels, and evaluates performance of direct reports.
• Leads continued development and implementation of an organizational grievance training program – regular training of departments and individual staff as required to assist in ensuring regulatory compliance
• Assists with the implementation and use of Bziagi, the G&A tracking and monitoring tool.
• Partners with departmental leaders to identify trends and improve operational processes that impact on member satisfaction and complaint numbers
• Provides guidance to Grievance Coordinator in the review, research, monitoring and routing of complaints, grievances and appeal cases to appropriate personnel to assure timely, corrective and documented resolution is achieved
• Manages challenging and/or complex grievances and appeals that require escalation and continued evaluation.
• Checks Complaints Tracking Module (CTM) daily (including weekends) and take appropriate steps to resolve any CTM complaints.
• Reviews, researches and directs complaints, grievances and appeal cases to appropriate personnel, and follows up to ensure that resolution has occurred, documentation is complete, required timeframes are met, and proper written communication of the decision has occurred. In most cases, prepares the written communication of the decision in plain written language. Coordinates additional follow up activities with appropriate department managers and/or leads and tracks to conclusion.
• Maintains grievance and appeal logs in a timely manner for both lines of business. This includes logging incoming grievance, tracking dispositions and maintaining timeliness of resolution as required by state and federal mandates.
• Maintains electronic files of all documentation, and appropriate follow up documentation in member and provider memo screens, or other computer system modules or databases as per current workflows.
• Ensures that all information to providers, members, employees and other appropriate persons is accurate, consistent and customer sensitive.
• When needed for specific types of grievances or appeals, prepares summaries for committee review, documents meeting discussions, and communicates decision in writing.
• Participates in internal committee and interdisciplinary meetings, reporting recent activity and analysis of trends, and makes recommendations for problem resolution and performance improvement
• Conducts and documents internal audits of the G&A department as required by QUEST Integration, CMS, or other regulatory agencies per format and timeframes specified.
• Ensures G&A department compliance with QUEST Integration, CMS, or other regulatory agencies.
• Other duties as required
• Responsible to maintain AlohaCare’s confidential information in accordance with AlohaCare policies, and state and federal laws, rules and regulations regarding confidentiality. Employees have access to AlohaCare data based on the data classification assigned to this job title

Required Qualifications:
• Bachelor of Science/Business Administration Degree in a related field
• 3-5 years of mid-level management experience in the Healthcare industry
• Minimum 2 years’ experience in Grievance and Appeals in a Managed Care Plan; or any combination of education and experience, which would provide an equivalent background.
• Outstanding inventory of management skills, oral, written and interpersonal communication skills, financial and business acumen, problem-solving skills, facilitation and analytical skills.
• Ability to ensure organizational compliance with all required rules, policies, and procedures.
• Requires operation of general office equipment to include; PC, fax/copy machine and ACD Midel Phones and proficient knowledge of Microsoft Office tools
• Achieves results, builds trust, communicate effectively, customer and quality focused.
• Ability to multi-task, adapt to changing priorities, manage a diversity of high priority projects in a fast-paced environment.
• Ability to organize and coordinate information with multiple departments and different staff levels, including management
• Strong problem solving and customer service skills
• Self-Started and takes Self-Initiative
• Experience with utilizing multiple data bases
• Experience in and Engages in Process Improvement
Preferred Qualifications:
• Experience in conducting training
• Knowledge of Medicaid, Hawaii QUEST Integration Program, and/or Medicare
Physical Demands/Working Conditions:
• Inside working conditions, the majority of the time
• No environmental hazards
• Ability to create and facilitate/conduct training; potentially with audiovisual presentations
• Sedentary Work: Exerting up to 20 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time.

AlohaCare is committed to providing equal employment opportunity to all applicants in accordance with sound practices and federal and state laws. Our policy prohibits discrimination and harassment because of race, color, religion, sex (including gender identity or expression), pregnancy, age, national origin, ancestry, marital status, arrest and court record, disability, genetic information, sexual orientation, domestic or sexual violence victim status, credit history, citizenship status, military/veterans status, or other characteristics protected under applicable state and federal laws, regulations, and/or executive orders.

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