Supervisor, Appeals and Grievances Clinical Operations RN

Job Summary

The Supervisor of Appeals and Grievances Clinical Operations (A&G) RN is responsible for executing the day-to-day clinical operations of the A&G department, and monitoring the A&G RN staff responsibilities and activities. This includes, but is not limited to, ensuring proper staffing and coverage; monitoring and evaluating departmental operations to ensure optimal efficiency, productivity, and effectiveness; documenting and appropriately addressing excellence or deviations in work, departmental, and organizational expectations; and conducting intermittent and annual performance evaluations. This role assists in triaging identified issues/problems and forming resolutions within the scope of work/licensure. The Supervisor is a subject matter expert (SME) in Appeals & Grievances and supporting regulations, policies, protocols, and procedures. This position serves as a formal and informal instructor, and escalates issues/concerns to the appropriate person when outside of their scope.

This position is responsible for assisting with and development and maintenance of a successful and cohesive unit, with a high level of productivity and accuracy to achieve the department's overall performance metrics. The Supervisor ensures all functions of the A&G department are operating in accordance with the organization's mission, values and strategic goals, which are focused on quality care delivery and continuous improvement; and are provided in a manner that is responsive and sensitive to the needs of L.A Care's culturally diverse membership.

The position supports the A&G Clinical Manager. This role also assists the A&G Leadership in identification of training needs including, but not limited to, collaborating in development of programs, training materials, competency checklist, and orientation checklists necessary to meet education and training needs of A&G staff.  The position supervises all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports.

Duties

Ensures adequate/appropriate distributions of workforce, assignments and time off requests.  Participates in the hiring and termination process providing recommendations with appropriate supporting documentation.

Monitors staff’s performance including productivity and compliance with regulatory requirements, compliance with policies.  Identifies, communicates and coaches to improve staff performance.  Develops tools, job aids, and workflows to optimize the process flow, performance and productivity of the A&G team. Completes intermittent and annual staff evaluations.

Serves as the primary resource for all business-related questions/issues raised by staff; escalates to appropriate leader/team when necessary.

Recommends and implements process improvement measures to achieve department's performance measures outcomes and goals.

Plans and oversees A&G clinical activities according to model of care, program description and policy and procedures to provide timely, quality care and services to members.

Duties Continued

Maintains all assigned reporting responsibilities, conducts regular audits to ensure compliance with community, industry and organizational standards including regulatory requirements. Serves as a super-user on electronic programs and systems used by the department.

Assists in the development of programs, workflows, tools, training materials, orientation checklists, and competency checklist necessary to meet educational needs.  Trains new staff, remediation of seasoned staff and cross training as needed in specified business lines. 

Serves as a leader and role model as well as technical and informational resource for staff and peers.

Fosters a culture that encourages employee contribution to ensure the department maintains an environment in which quality flourishes.

Serves as a member/resource/liaison to the A&G Operations Team.

Recommends resources to improve performance standards in terms of Appeals & Grievances.  Collaborates with peers and colleagues within the organization to address process improvements, member's needs, department and organizational enhancements and communicate development as appropriate.

Participates on internal and external committees as delegated or assigned.

Serves as a consultant to other departments or organizations as needed.

Performs other duties as assigned.

Education Required

Education Preferred

Experience

Required:

Minimum of 8 years of acute/clinical care experience.

Minimum of 2 years of experience in RN clinical operations in an acute care or health plan setting.

Minimum of 2 years in a lead/supervisory experience.

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

Skills

Required:

Knowledge of state, federal and regulatory requirements in Appeals/Care/Case/Utilization Management/Quality.

Strong verbal and written communication skills.

Computer literacy with proficiency in Microsoft Word, Excel, etc. and ability to learn core departmental computer systems and software.

Excellent organizational, time management, and interpersonal skills.

Must be detailed-oriented, energetic, and an enthusiastic team player.

Must be able to work independently.

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