The Manager of Grievance & Appeals serves as the team leader for the production team who receives, investigates, and responds to all member grievances, appeals, state hearings, and expedited cases. Manages day-to-day activities, clinical solutions, and is responsible for the timeliness, accuracy and quality investigation of all cases. Will manage the production team consisting of Grievance Clinical Nurses, Supervisors of Grievance Coordinators, and Grievance Resolution Specialists. Activity engaged in casework, monitors reoccurring issues, explores root causes, and presents monthly trends to the Associate Director of Grievance & Appeals.
Serves as a motivational leader, supports professional development of team, implements operational efficiencies, and considers new clinical approaches that minimizes Partnership HealthPlan’s risk. Promotes a positive member experience, acts as an innovative problem solver, and helps the team arrive at long-term solutions for their casework. Embraces accountability, strong work ethics and integrity. May represent the Grievance & Appeals Department while serving on and/or presenting at internal and external committees.
Provides strategic leadership, training, and direction to grievance staff by:
Education and Experience
Bachelor’s degree in Business, Nursing, Healthcare Management, or other related field required. Master’s degree or Registered Nurse licensure preferred. At least 3 years’ experience in management. Experience in grievance and appeals, case management, customer service, account management, or serving disgruntled customers strongly preferred. Will manage onsite and telecommuting staff. Excellent written and interpersonal communication skills. Experience presenting presentations. Demonstrated conflict resolution and mediation skills. Confident, autonomous, solution driven, proactive, detail oriented, high standards of excellence, nonjudgmental, diplomatic, resourceful, intuitive, dedicated, and resilient.
Special Skills, Licenses and Certifications
Thorough working knowledge of managed care concepts, policies, and procedures. Ability to understand, interpret, and prepare documentation used in State Hearing cases.
Prefer valid Registered Nurse licensure. Valid California driver’s license and proof of current automobile insurance compliant with Partnership HealthPlan policy are required to operate a vehicle and travel for company business.
Performance Based Competencies
Ability to learn quickly and acquire in-depth knowledge of software used at Partnership HealthPlan. Excellent analytical skills to troubleshoot and resolve system problems. Able to develop procedures and document extensively and clearly. Excellent oral and written communication skills. Excellent analytical and interpersonal skills. Ability to assess and resolve customer complaints, problems, and issues in an effective manner. Excellent organizational skills. Ability to prioritize issues, use good judgment, and handle sensitive issues with confidentiality, tact, and diplomacy.
Work Environment And Physical Demands
Ability to use a computer keyboard. More than 60% of work time is spent at a computer monitor. May travel up to 25%.
All HealthPlan employees are expected to:
IMPORTANT DISCLAIMER NOTICE
The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.