Supervisor, Customer Solution Center Appeals and Grievances

Job Summary

The Supervisor, Customer Solution Center Appeals and Grievances is responsible for direct supervision and support of the team responsible for the intake, research, resolution, tracking, trending and reporting within the Appeals and Grievances department. This position will be accountable for leading and directing the work for the Appeals and Grievances department by monitoring the research, negotiation and resolution of all types of appeals and grievances to ensure thorough investigations are completed as outlined in the company policies and procedures. Provides support and ownership of cases identified as escalated, complex and/or multi-issue appeals and grievances on an as needed basis. Collaborates with internal departments to ensure timely resolution. This position will be responsible for analyzing and trending for all appeals and grievances. Responsible for the development and maintenance of the appeal and grievance Policies and Procedures, workflows, Member correspondence, and training as needed, or on an annual basis. The position supervises all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports.

Duties

Evaluate daily reports to ensure individual and team Key Performance Indicators (KPIs), SLAs, Performance Scorecards meet regulatory requirements.       

Provide direction to staff for complex/sensitive member and provider inquiries, concerns, complaints, appeals, and grievances. Conduct weekly 1:1s with direct reports.

Build and maintain strong working relationships with internal departments involved in appeal and grievance resolution.       

Development, maintenance and implementation of P&Ps, workflow and training.     

Audit preparation and providing recommendations for Corrective Action Plans from state regulatory agencies.

Supervise 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.

Perform other duties as assigned.

Duties Continued

Education Required

Education Preferred

Experience

Required:

At least 3 years in a healthcare setting in Grievances and Appeals, Compliance, Claims or Call Center.

At least 2 years of leading process, program, or staff or supervisory experience.

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

Preferred:

Previous experience in Managed Health, preferably in Customer Service, Appeals and Grievances and/or Claims.

Skills

Required:
Ability to manage and organize large volumes of data.

Knowledge of regulatory and accreditation entities and their requirements.

Excellent verbal and written communication skills and interpersonal skills.

Good working knowledge of licensure and regulatory requirements, and accreditation standards.

Ability to work independently.

Ability to solve complex issues and identify creative solutions.

Computer ease and literacy with Microsoft Office (Word, Excel, Power Point, Access,  and Visio).

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