CareSource
Team Lead, Grievance & Appeals Resolution (Licensure required)
CareSource, Dayton, Ohio, United States, 45402
Job Summary:
The Team Lead, Grievance and Appeals Resolution oversees the day-to-day performance of grievance and appeals resolution specialists and provides oversight of the Health Insurance Casework System (HICS), the Revenue Cycle Operations and the CTM system, while ensuring all regulatory, compliance and HIPAA guidelines are met for the current Marketplace, Medicaid and Medicare lines of business and future lines of business.
Essential Functions:
Responsible for full resolution of HICS and CTM cases within regulatory timeframes and defined requirements
Supervise staff for quality review, performance feedback, disciplinary issues and merit/bonus appraisal review
Meet all monthly, annual and semi-annual reporting deadlines
Work with Regulatory Compliance Officers to ensure that requests are resolved within time lines and tracked for reporting
Monitor Marketplace, Medicaid and Medicare processes to ensure that all regulatory requirements are followed
Work with support departments and compliance officers to ensure policies and procedures are current
Establish an audit process
Responsible for evaluating operations and identifying process improvement needs.
Identify irregular trends with HICS processes, RCO processes and the CTM system ; work with other areas as appropriate to identify root causes and appropriate steps for resolution
Responsible for staffing, ensure that open positions are filled, and evaluate future staffing needs
Review validation reports to ensure that grievances and appeals as it relates to the HICS and RCO processes are accurate
Develop and monitor workflows for Grievance and Appeals Department as it relates to HICS and RCO processes that ensures maximum level of productivity
Monitor member-facing departments to ensure that grievances and appeals are resolved and reported to the Grievance and Appeals Department, for HICS and RCO.
Conduct audits and provide feedback to all areas that submit grievances and appeals, as it relates to the HICS and RCO processes.
Facilitate timely resolution of member and provider issues.
Ensure that Grievance and Appeals Specialists for the HICS and RCO processes are available to respond to incoming calls
Coordinate incoming information and disseminate to staff to ensure accuracy of communication to internal and external customers.
Create, review, revise and enforce company and departmental policies and procedures
Act as the contact point for CareSource on operational issues to all regulatory bodies in existing and future lines of business
Proactively keep the management team apprised of the team's performance, projects and issues
Provide support to the Service Center during high call volume or other support as needed
Develop, deliver or coordinate the delivery of grievance and appeals training to other areas as needed. Performs any other job related duties as requested.
Education and Experience:
Associates degree in business, finance or related field required
Bachelor's degree in business, finance or related field preferred Equivalent years of relevant work experience may be accepted in lieu of required education Four (4) years years of experience in billing, credit and collections, or customer service experience required
Previous supervisory/leadership experience preferred Competencies, Knowledge and Skills:
Basic computer skills including Microsoft Word, Excel and PowerPoint
Basic experience with ACD systems
Basic experience with Call Management Systems
Communication skills
Prior supervisory skills
Ability to work independently and within a team environment
Attention to detail
Familiarity of the healthcare field and knowledge of Marketplace, Medicaid and Medicare.
Critical listening and thinking skills
Training/teaching skills
Strategic management skills
Negotiation skills/experience
Proper grammar usage
Technical writing skills
Time management skills
Proper phone etiquette
Customer service oriented
Decision making/problem solving skills
Strong language skills
Ability to write comprehensive statements using proper grammar and sentence structure Licensure and Certification:
Current, unrestricted State Insurance License in Accident and Health within state(s) of assigned territory is/are required or ability to achieve license(s) within 30 days of hire
Applicable certification as required within state(s) of assigned territory or ability to achieve certification(s) within 30 days of hire and annual recertification each year thereafter is required
For positions in states that operate under the Federally Facilitated Marketplace (FFM) and offer Marketplace plans, candidates must obtain certification from the Health Insurance Marketplace Working Conditions:
General office environment; may be required to sit or stand for extended periods of time Up to 15% (Occasional) travel based on the needs of the department may be required Compensation Range: $61,500.00 - $98,400.00 CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package. Compensation Type: Salary Competencies: - Fostering a Collaborative Workplace Culture - Cultivate Partnerships - Develop Self and Others - Drive Execution - Influence Others - Pursue Personal Excellence - Understand the Business This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds. #LI-SD1
The Team Lead, Grievance and Appeals Resolution oversees the day-to-day performance of grievance and appeals resolution specialists and provides oversight of the Health Insurance Casework System (HICS), the Revenue Cycle Operations and the CTM system, while ensuring all regulatory, compliance and HIPAA guidelines are met for the current Marketplace, Medicaid and Medicare lines of business and future lines of business.
Essential Functions:
Responsible for full resolution of HICS and CTM cases within regulatory timeframes and defined requirements
Supervise staff for quality review, performance feedback, disciplinary issues and merit/bonus appraisal review
Meet all monthly, annual and semi-annual reporting deadlines
Work with Regulatory Compliance Officers to ensure that requests are resolved within time lines and tracked for reporting
Monitor Marketplace, Medicaid and Medicare processes to ensure that all regulatory requirements are followed
Work with support departments and compliance officers to ensure policies and procedures are current
Establish an audit process
Responsible for evaluating operations and identifying process improvement needs.
Identify irregular trends with HICS processes, RCO processes and the CTM system ; work with other areas as appropriate to identify root causes and appropriate steps for resolution
Responsible for staffing, ensure that open positions are filled, and evaluate future staffing needs
Review validation reports to ensure that grievances and appeals as it relates to the HICS and RCO processes are accurate
Develop and monitor workflows for Grievance and Appeals Department as it relates to HICS and RCO processes that ensures maximum level of productivity
Monitor member-facing departments to ensure that grievances and appeals are resolved and reported to the Grievance and Appeals Department, for HICS and RCO.
Conduct audits and provide feedback to all areas that submit grievances and appeals, as it relates to the HICS and RCO processes.
Facilitate timely resolution of member and provider issues.
Ensure that Grievance and Appeals Specialists for the HICS and RCO processes are available to respond to incoming calls
Coordinate incoming information and disseminate to staff to ensure accuracy of communication to internal and external customers.
Create, review, revise and enforce company and departmental policies and procedures
Act as the contact point for CareSource on operational issues to all regulatory bodies in existing and future lines of business
Proactively keep the management team apprised of the team's performance, projects and issues
Provide support to the Service Center during high call volume or other support as needed
Develop, deliver or coordinate the delivery of grievance and appeals training to other areas as needed. Performs any other job related duties as requested.
Education and Experience:
Associates degree in business, finance or related field required
Bachelor's degree in business, finance or related field preferred Equivalent years of relevant work experience may be accepted in lieu of required education Four (4) years years of experience in billing, credit and collections, or customer service experience required
Previous supervisory/leadership experience preferred Competencies, Knowledge and Skills:
Basic computer skills including Microsoft Word, Excel and PowerPoint
Basic experience with ACD systems
Basic experience with Call Management Systems
Communication skills
Prior supervisory skills
Ability to work independently and within a team environment
Attention to detail
Familiarity of the healthcare field and knowledge of Marketplace, Medicaid and Medicare.
Critical listening and thinking skills
Training/teaching skills
Strategic management skills
Negotiation skills/experience
Proper grammar usage
Technical writing skills
Time management skills
Proper phone etiquette
Customer service oriented
Decision making/problem solving skills
Strong language skills
Ability to write comprehensive statements using proper grammar and sentence structure Licensure and Certification:
Current, unrestricted State Insurance License in Accident and Health within state(s) of assigned territory is/are required or ability to achieve license(s) within 30 days of hire
Applicable certification as required within state(s) of assigned territory or ability to achieve certification(s) within 30 days of hire and annual recertification each year thereafter is required
For positions in states that operate under the Federally Facilitated Marketplace (FFM) and offer Marketplace plans, candidates must obtain certification from the Health Insurance Marketplace Working Conditions:
General office environment; may be required to sit or stand for extended periods of time Up to 15% (Occasional) travel based on the needs of the department may be required Compensation Range: $61,500.00 - $98,400.00 CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package. Compensation Type: Salary Competencies: - Fostering a Collaborative Workplace Culture - Cultivate Partnerships - Develop Self and Others - Drive Execution - Influence Others - Pursue Personal Excellence - Understand the Business This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds. #LI-SD1