Lead Appeals and Grievances

Job Summary

The Lead Appeals and Grievances is responsible for assisting with the development of a successful and cohesive Appeals and Grievance unit, with a high level of productivity to achieve the department's overall performance metrics, and to meet and/or exceed member satisfaction. Responsible for the day to day oversight of Appeals and Grievance Specialist by closely monitoring work, providing feedback on performance, trains, coaching, mentoring, motivating, and ensures compliance to policies, procedures and regulations. Ensures that all Appeals and Grievances are processed accurately and timely. Leads and works closely with assigned team on a daily basis. This position may provide feedback to management on performance of staff. Ensures team effectiveness and project completion.

Duties

Leads day to day activities of the Appeals and Grievances team including but not limited to: Providing direction to the team, handling internal or external questions or issues raised in relation to Appeals or Grievances and recommending and implementing resolution, new processes and or process improvement. Assists Supervisor to ensure that Specialist provide accurate, timely, and quality responses. Ensures that all departmental policies, procedures and standards are being followed to meet departmental and organizational goals. Assists the Supervisors to ensure that deviations in performance are identified in advance and process changes are made to redirect performance to acceptable levels. Provides accurate and timely written and/or verbal statistical reports that includes historical and/or current data to aid in projecting or evaluating Compliance status. Assists Supervisor in reviewing the Specialists overall quality and accuracy, provide education and training where applicable to remediate reoccurrences. Supports and leads the distribution and redistribution of inventory and/or assignments as needed. Processes all case types including regulatory cases and provides recommendations towards resolution.

Trains and motivates staff. Ensures appropriate compliance standards are followed and maintained. Works closely with Supervisors to create and/or modify Desk Level Procedures. Leads the work of assigned staff; regularly assigns and checks the work of others, providing guidance, training and feedback on performance to department management. Oversees the daily office workflow, develops and recommends enhancements to process and procedures.

Works closely with management to review performance and quality standards on an ongoing basis as well as motivational programs needed to achieve regulatory standards.

Acts as a back-up to the Supervisor leading meetings and handling escalations as required.

Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval.

Guides the assigned staff in ensuring that the team's work is completed effectively. May assist in assigning tasks and communicating project goals.

Responsible for the day-to-day execution and implementation of projects and tasks. Facilitates team dynamics, motivates assigned staff and fosters an environment conducive to effective collaboration and productivity.

Provides direct guidance, instruction and support specific projects or tasks.

Participates in team problem-solving, decision-making, and conflict resolution.

Performs other duties as assigned.

Duties Continued

Education Required

Education Preferred

Experience

Required:

At least 4 years of Appeals and Grievances experience and working with firm deadlines with proven ability to interpret and apply regulations.

At least 1 year of leading process, program, or staff experience.

Preferred:

Experience in working with the disadvantage population, Medi-Cal, Covered California, and Cal MediConnect. One year lead experience in a health plan/healthcare.

Skills

Required:

Strong knowledge of Centers for Medicare and Medicaid Services (CMS), Department of Managed Health Care (DMHC), and Department of Health Care Services (DHCS) regulations.

Knowledge of Medical Terminology.

Excellent written and verbal communication skills. Possess skillset to effectively communicate with all levels including but not limited to members, peers, leaders, physicians, executives, and regulatory entities.

Strong analytical, coaching/mentoring skills, team building.

Ability to work effectively with diverse team members.

Ability to troubleshoot problem areas and recommend effective alternative solutions to handle irate members and provide optimal customer service for internal and external customers.

Flexible with time and ability to work weekends.

Ability to multitask and streamline day-to-day operations, policies and procedures.

Advance PC skills including Word, Excel and Access.

Must be organized, detail oriented, able to exercise strong independent judgment; poses conflict resolution and persuasion skills.

Ability to work closely with a team in a collaborative and interactive environment.

Ability to adjust to changing circumstances within the team.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information

This position requires work after hours, on weekends, holidays, a hybrid remote schedule, occasional flexibility in hours/shift in critical situations and work on-call.

This position requires handling various caseloads and flexibility to adapt to changing priorities which may include but not limited to redistributed work assignments, team projects, and other priorities as assigned