Manager, Grievance & Appeals

Manager, Grievance & Appeals

Job Description

Department(s): Grievance & Appeals Resolution Services (GARS)
Reports to: Director, GARS
FLSA status: Exempt
Salary Grade: O – $105,000 – $149,000

Job Summary

This position will manage the day-to-day operations of the Grievance and Appeals Resolution Services (GARS) department. Ensures service standards, adherence to regulatory requirements, established policies and procedures regarding the appeals and grievance process are met. The incumbent works with CalOptima management staff with close interface with program Medical Directors in resolving grievance and appeal cases. The incumbent communicates with all levels of internal staff, regulatory agencies, health networks, providers, vendors, community-based organizations, and medical groups.

Position Responsibilities:

• Hires, trains, and develops department staff.
• Manages and makes recommendations on development and maintenance of an effective appeals and grievance process and system consistent with CalOptima policy and stated goals, including, but not limited to mechanisms to monitor grievances and appeals involving Department of Managed Healthcare, Department of Health Care Services, Independent Medical Review, Medi-Cal State Hearings, Office of Administrative Hearings and Appeals, Centers for Medicare and Medicaid (CMS) and external review agencies for CMS.
• Develops, implements, maintains, and reviews the adequacy of the CalOptima grievance systems, reporting, policies, and functions to achieve stated goals, including, but not limited to, grievance resolution and timely responsiveness for all lines of business, provider and member or other stakeholders, and applicable accreditation standards to ensure compliance with all relevant regulatory requirements pertaining to GARS.
• Coordinates with the Director of GARS in providing trends to the internal and external departments.
• Works with Audit and Oversight and key departments to ensure internal departments and external partners (i.e. health networks and delegates) are up to date with regulatory, departmental and organizational changes impacting the grievance and appeals processes. Works with internal management staff, including medical directors, in the resolution of grievances and appeals.
• Ensure timely and effective data collection, summarization, integration, and reporting, including, but not limited to, productivity, status and trend reports for specific committees such as the Quality Improvement Committee, Grievance and Appeals Committee, Quality Assurance Committee of the Board of Directors and other ad hoc reporting as required.
• Creates and implements staff and departmental performance goals.
• Serves as CalOptima’s primary point of contact and subject matter expert related to grievance and appeals.
• Assists in the development of policies, procedures and standards for all GARS activities and member or provider processes.
• Participates in Department of Managed Healthcare (DMHC), Department of Health Care Services (DHCS), and Centers for Medicare and Medicaid (CMS) audits related to grievance and appeals for all CalOptima programs.
• Collaborates with the Director of GARS in identifying and analyzing trends and makes recommendations for improvement.
• Assures adequate and timely communication with GARS staff, other CalOptima departments, and external customers on individual grievance and appeal issues or trends.
• Stays current on the local, state, and federal health care environment, identifying issues that may impact CalOptima’s programs as it relates to grievance and appeals.
• Represents the GARS department at various meetings as applicable.
• Other projects and duties as assigned.

Possesses the Ability To:

• Provide management and leadership in department including staff development.
• Ensure timely resolution of member related problems.
• Maintain effective collaborative relationships with other departments, programs, agencies and the general public.
• Multi-task in projects and their respective activities, timelines and issues.
• Monitor staff productivity and cases; identify high risk issues and escalate as appropriate.
• Establish and maintain effective working relationships with internal and external entities.
• Demonstrate strong verbal and written communication skills including presentations for internal/external stakeholders.
• Assist in the formulation of policies and procedures; understand and interpret policies, procedures and regulations.
• Initiate and complete work independently and efficiently, with minimal supervision with highly confidential information, per HIPAA regulations.

Experience & Education:

• Minimum 2 years of health care management experience, preferably in managed care environment in related area of responsibility, i.e., grievances and appeals utilization management, quality management.
• 2 years of supervisory experience.
• Strong interpersonal skills including coaching staff, and handling conflict resolution, implementing initiatives or projects, and collaborating with other professional and non-clinical staff required.

Preferred Qualifications:

• Bachelor’s degree in a related field or equivalent work experience is preferred.
• HMO, Medi-Cal/Medicaid, Medicare and insurance experience or relevant government client or public service experience.

Knowledge of:

• Medi-Cal and Medicare program regulations, including State and Federal standards and regulations for member and provider rights and responsibilities.
• Knox-Keene licensing standards.
• Knowledge and understanding of covered benefits specified in CalOptima contracts.
• Principles and practices of the managed health care systems, and medical administration and NCQA Accreditation standards.
• Appropriate techniques to serve diverse social and ethnic groups.

CalOptima is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima wants to have qualified employees in every job position. CalOptima prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.

If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. You can request reasonable accommodations by contacting Human Resources Disability Management at 657-900-1134.

Job Location: Orange, California

Position Type:

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