Manager, Appeals and Grievances General Operations (RN-Clinical)

Job Summary

The Manager, Appeals & Grievances (A&G) & General Operations (Clinical) is responsible for the daily oversight of clinical appeals and grievances functions within the Appeals & Grievances Department to ensure clinical grievances, complaints, appeals and complex issues are investigated and resolved using regulatory guidance across all lines of business. Provides direct supervision to the A&G clinical team and the unit that supports them in order to assure operational effectiveness which includes the implementation and adherence to L.A. Care's Policies & Procedures that meet Centers for Medicare and Medicaid Services (CMS), the California Department of Health Care Services (DHCS), the California Department of Managed Health Care (DMHC), the Managed Risk Medical Insurance Board (MRMIB), National Committee for Quality Assurance (NCQA) and other rules/ regulations/ standards.
 
The Manager is responsible for establishing and monitoring processes to oversee and coordinate the identification, documentation, reporting, investigation and resolution of all member appeals and grievances in a timely and culturally-appropriate manner. Coordinates, tracks, and resolves internal and external appeal and grievance complaints for L.A. Care Plan Partners, including identifying opportunities for improvement.

This position will be a role model for integrity and will establish and maintain effective professional work relationships, working collaboratively with all levels of management and business owners to help guide the discipline of planning, organizing, securing, managing, leading, and controlling resources to achieve specific goals.

Manages all aspects of running an efficient  team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports. 

Duties

Manage and oversee the handling of clinical grievances and appeals, for L.A. Care and Plan Partner members. Establishes and oversees processes and all relevant member correspondence for accuracy, clarity, and cultural appropriateness and sensitivity.
 
Review and monitor procedures for identifying quality of care issues and work collaboratively with cross-functional departments to appropriately address and resolve member grievances. Serve as the Key Contact for State Fair Hearings, internal and external audits, DMHC and DHCS inquiries. Review and monitor procedures for identifying quality of care issues and work collaboratively with cross-functional departments to appropriately address and resolve member and provider grievances.

Responsible for timely daily operations in the A&G Clinical Services Unit and other general operations units.  Ensures timely appeal and grievance reporting to regulatory agencies, internal Regulatory Affairs and Compliance Department, internal Quality Oversight Committee, etc. Collaborates with cross-functional departments  to ensure the use of appropriate appeal and grievance issue codes, timely resolution, and refers to community partners as appropriate.  

Lead, participate and provide representation of the A&G Team at Internal and External meetings/ workgroups and acts as the point person for A&G Programs especially the Clinical Programs.

Develop and execute on strategic opportunities to improve the overall appeals & grievance process. Create a best in clinical appeals process that is efficient and effective in managing member appeals.

Work cross functionally and collaboratively within Appeals and Grievances with key internal partners to build a high functioning, results oriented environment and organization. 

Duties Continued

Partner with internal and external stakeholders to build and maintain collaborative relationships and partnerships. Identify areas of connection to leverage and create added value for L.A. Care.

Provide input into the development of automation to guide the team to process efficiencies for all lines of business while maintaining compliance and manageable workloads for staff.

Responsible for maintaining and updating on an annual basis, or as necessary, appeal and grievance policies and procedures, member correspondence, etc., consistent with regulatory changes.  Develop and maintain inventory reports for the appeals process ensuring appropriate productivity, compliance, and inventory management.  

Identify and implement continuous business process improvement recommendations to leverage organizational added value to the Appeals and Grievances Department.  Develop and implement short and long-term strategies to improve team results, reducing administrative expenses.

Manage staff , including, but not limited to: monitoring of day to day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others. Supervision of the Clinical Services unit and general operations within Appeals and Grievances. Maintain a team of top talent, providing a culture of teamwork and collaboration. 

Perform other duties as assigned

Education Required

Education Preferred

Experience

Required:
6-8 years of clinical acute care experience with at least 3 years of experience with health care grievance and/or appeals issues, preferably in a managed care or Medicaid health Plan environment and/or public services or public benefits programs.

At least 3+ years of management level operations leadership experience.

Experience working with firm deadlines, regulators, detail oriented with the ability to interpret and apply regulations

Experience building relationships with organizations and business partners.

Preferred:  
Managed care experience

Skills

Required:
Excellent analytical, problem solving, planning and implementation skills.

Demonstrated strong writing and communication skills.

Demonstrates excellent leadership, communication, and negotiation skills with the ability to interact and influence all levels of the organization including executive management and key decision -makers.

Demonstrates professional judgement, and critical thinking, to promote the delivery of quality, cost-effective care.

Time management and priority setting skills.

Excellent understanding of NCQA, DMHC, DOI, DHCS, and CMS regulatory requirements.

Knowledge of Coordination of Care, Medicare and Medi-Cal regulations, prior authorization, level of care and length of stay criteria sets.

Able to work effectively with various internal departments/service areas, L.A. Care's plan partners, participating provider groups, and other external agencies.

Able to operate PC-based software programs including proficiency in Word, Excel and PowerPoint presentations.

Excellent verbal, written communication and presentation skills.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information