Elevance Health
Position Title:
Manager II Grievance & Appeals Job Description: The
Manager II Grievance & Appeals
is responsible for management oversight of grievances and appeals departmental units to investigate, resolve, and respond to grievances and appeals, manages inventory and production levels, and operational and plan risk, ensures quality, and regulatory compliance. This role specifically oversees the IRE Team. How you will make an impact: Coordinates Grievance and Appeals Committee Meetings. Assists grievance and appeals leadership in regulated audits. Oversight of the IRE portions of Medicare audits and universe production. Serves as a resource for complex issues and interpretation of claims, provider contracts and data, eligibility, member contracts, benefits, clinical decisions, pharmacy on pre-service and post service appeals and grievances related to non-clinical and clinical services, quality of service and quality of care issues including executive and regulatory grievances. Oversees and implements new subsystems, procedures, techniques and supports digital automation objectives. Analyzes and develops strategies by achieving performance thresholds within budgetary guidelines. Monitors trends and analyzes grievance and appeals data to identify and recommend plan and policy changes and to ensure state and federal regulatory compliance and resolution within the regulatory timeframes. Ensures programs support overall QI program and meet regulatory compliance/accreditation and the company standards. Hires, trains, coaches, counsels, and evaluates performance of direct reports. Minimum qualifications: Bachelor’s degree and a minimum of 5+ years grievance & appeals experience and a minimum of 3 years of management experience in the healthcare industry; or any combination of education and experience which would provide an equivalent background. For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. Preferred Skills, Capabilities and Experiences: Three years of managerial experience is strongly preferred Experience with IRE/Maximus and Medicare compliance, programs, guidelines, and processes are strongly preferred. Solid knowledge of Medicare Grievance and Appeals rules and regulations is highly preferred. Demonstrated critical thinking and problem-solving abilities are highly preferred. Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws.
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Manager II Grievance & Appeals Job Description: The
Manager II Grievance & Appeals
is responsible for management oversight of grievances and appeals departmental units to investigate, resolve, and respond to grievances and appeals, manages inventory and production levels, and operational and plan risk, ensures quality, and regulatory compliance. This role specifically oversees the IRE Team. How you will make an impact: Coordinates Grievance and Appeals Committee Meetings. Assists grievance and appeals leadership in regulated audits. Oversight of the IRE portions of Medicare audits and universe production. Serves as a resource for complex issues and interpretation of claims, provider contracts and data, eligibility, member contracts, benefits, clinical decisions, pharmacy on pre-service and post service appeals and grievances related to non-clinical and clinical services, quality of service and quality of care issues including executive and regulatory grievances. Oversees and implements new subsystems, procedures, techniques and supports digital automation objectives. Analyzes and develops strategies by achieving performance thresholds within budgetary guidelines. Monitors trends and analyzes grievance and appeals data to identify and recommend plan and policy changes and to ensure state and federal regulatory compliance and resolution within the regulatory timeframes. Ensures programs support overall QI program and meet regulatory compliance/accreditation and the company standards. Hires, trains, coaches, counsels, and evaluates performance of direct reports. Minimum qualifications: Bachelor’s degree and a minimum of 5+ years grievance & appeals experience and a minimum of 3 years of management experience in the healthcare industry; or any combination of education and experience which would provide an equivalent background. For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. Preferred Skills, Capabilities and Experiences: Three years of managerial experience is strongly preferred Experience with IRE/Maximus and Medicare compliance, programs, guidelines, and processes are strongly preferred. Solid knowledge of Medicare Grievance and Appeals rules and regulations is highly preferred. Demonstrated critical thinking and problem-solving abilities are highly preferred. Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws.
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