Appeals and Grievances Team Leader- Remote

The purpose of this position is to provide lead level support to the Appeals and Grievances team with the direct assistance of the Director of Claims Operations. The purpose of the position includes overseeing the processing, tracking, and following up on all medical necessity and administrative denials, appeals, grievances, and disputes for Medicare Advantage members in accordance with Medicare guidelines and regulations. The Appeals and Grievances Team Leader is a critical team player who works in a fast-paced, ever-changing environment with a passionate team and must deliver daily.

ESSENTIAL FUNCTIONS: To perform this job, an individual must perform each essential function satisfactorily with or without a reasonable accommodation.

Capture, investigate and respond to all complaints regarding customer grievances and appeals in addition to overseeing claim payment disputes provision of service and benefit coverage issues

Conduct pertinent research to evaluate, answer, and close appeals

Ensure appropriate resolution to inquiries, grievances and appeals within specified timeframes established by either regulatory/accreditation agencies or customer needs; ensure appropriateness of the response in compliance with State and Federal guidelines

Assist members when filing appeals; educate members, document and route the information appropriately

Prepare response letters, notifications, and acknowledgements for members and provider complaints, grievances and appeals

Maintain grievance information and supporting documentation in accordance with all state, federal, NCQA, URAC and other regulatory agency standards / regulations

Escalate issues appropriately or work with other departments to resolve member issues

Ensure all HIPAA and State requirements/regulations are always adhered to

Identify issues and root causes of appeals and disputes for plan management and compliance

Identify and report trends and/or areas of opportunities to supervisor

Maintain and update appeal and grievance policies and procedures, member correspondence materials, and process manuals

Perform internal audits of grievance and appeals process

Maintain privacy and confidentiality of records, conditions, and other information relating to residents, employees and facility

Encourage an atmosphere of optimism, warmth and interest in patients’ personal and health care needs

Meet critical time frames on a frequent and regular basis

Required Skills:

Excellent communication skills and active listening

Positive, engaging customer service skills

Meet critical time frames on a frequent and regular basis

Work cooperatively with internal departments and external stakeholders

Perform in potentially stressful situations, such as state, federal, NCQA, URAC or other regulatory/accrediting agency audits

Required Work Experience:

Minimum (3) three years’ health plan experience; insurance, compliance, managed care, or quality assurance preferred

Minimum (3) years of Grievance and appeals experience preferred, specifically within a Medicare and/or Medicare Advantage context

Minimum two years of demonstrated leadership skills in claims and/or appeals and grievances Proven track record for improving processes and problem-solving skills

Ability to motivate team members while also possessing strong leadership skills

Experience working with physicians and clinicians in the appeals and grievance space, preferred

Knowledge and understanding of complaint and appeal procedures

Knowledge of managed care, particularly utilization management processes

Knowledge of NCQA, HEDIS or general accreditation requirements and guidelines for utilization management, denials and appeals

Familiarity with Appeals processes and regulatory requirements related to

Customer service experience

Proven ability to problem-solve and make solid and well-researched decisions

Qualifying criminal background

Education Requirements:

High school diploma required

Associates degree preferred

Successfully completed college courses in relevant fields to compensate for experience preferred

Medicare experience preferred

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