Manager, Customer Solution Center Appeals and Grievances

Job Summary

The Manager, Customer Solution Center Appeals and Grievances is responsible for the centralized intake, logging and triage process for all member appeals and grievances. The Manager oversees the resolution of member appeals and grievances for all product lines (Medi-Cal, Medi-Cal Direct, Medicare, PASC-SEIU and L.A. Care Covered) in a manner consistent with regulatory requirements from the Department of Managed Health Care, Department of Health Care Services, Centers for Medicare & Medicaid Services, as well as requirements from the National Committee on Quality Assurance (NCQA) and L.A. Care policies and procedures. This position ensures the proper handling of member complaints whether presented by members, their authorized representative, the Ombudsman office, state contractors, member advocates, L.A. Care Board Members, providers, etc.

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.

Ensures timely appeal and grievance reporting to regulatory agencies, internal Regulatory Affairs and Compliance Department, internal Quality Oversight Committee, etc. Collaborates with internal departments (Member Services, Provider Network Operations, Claims, Utilization Management, Pharmacy, and Quality Management) to ensure the use of appropriate appeal and grievance issue codes, timely resolution, and refers to community partners as appropriate.

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. 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 member grievances and appeals, for L.A. Care and Plan Partner members as requested. Establishes and oversees processes and all relevant member correspondence for accuracy, clarity, and cultural appropriateness and sensitivity. Review grievance and State Fair Hearing files for compliance with Policies and Procedures and directives. Review and monitor procedures for identifying quality of care issues and work collaboratively with multiple departments (Claims, Provider Network Operations, Utilization Management, Quality Management, Pharmacy) 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 multiple departments (Claims, Provider Network Operations, Utilization Management, Pharmacy) to appropriately address and resolve member and provider grievances.

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 enhacements, among others.

Works with internal stakeholders to analyze monthly/quarterly grievance reports and PPG and Plan Partner data. Participates in Quality Oversight Committee, Member Service Quality Committee, and QI Improvement Committee and others as necessary.

Work collaboratively with state entities, providers, plans, community advocates, and key stakeholders (member representatives) to address cumbersome administrative issues negatively impacting members' access to care.

Perform other duties as assigned.

Duties Continued

Education Required

Education Preferred

Experience

Required:

At least 5 years of experience resolving health care eligibility, access, grievance and appeals issues, preferably in health services, legal services and/or public services or public benefits programs.

At least 2-4 years supervisory/management experience.

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

Equivalency:  Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.

Skills

Required:
Strong customer service and excellent oral and written communication skills. 

Health Plan background a plus, along with strong advocacy background. 

Strong analytical and conflict resolution skills as well as persuasion skills. 

Proficient in MS Office applications, Word, Excel, Power Point, and Access.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information