Director, Appeals & Grievances – Boston, MA - HEALTH CARE Salary /$80,000 - $140,000 Est. comm $8,000 - $12,000 USD

Preview of job requirements

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  Minimum of 4 years of managerial experience.

  
  


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  Must have experience working with CMS, regulated Appeals & Grievances function.

  
  


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  Experience working with external regulators 

  
  


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  8-10 years of experience working with CMS regulated A/G functions, and at least 4 years in a management capacity

  
  


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  Experience presenting complex clinical/confidential information to regulators

  
  


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  Experience addressing complaints and turning negative experiences into positive outcomes

  
  

This position plays a key role in continued strategy to lead the nation in providing consumer-centered care and services to individuals with complex health and social needs. The Director of A/G provides strategic and operational leadership and management oversight to ensure that:

1) the end-to-end appeal and grievance process is in full compliance with all State and Federal regulatory requirements; and

2) appeals and grievances serve as important member inputs into the development and implementation of innovations and improvements to best meet CA member needs. The Director will provide direction, communication, and support both to the Appeals and Grievances operational team as well as to clinical and service teams across the organization to facilitate timely identification, intervention and resolution of the complaint intake and reporting processes for both the Senior Care Options (SCO) and One Care Programs. The Director will collaborate with Member Voices Program leadership to make sure that member complaints are well understood and integrated into the body of member data that underlies the Member Journey Map, resulting root cause analyses, and strategic improvement efforts. In addition, this position directs the preparation of data and regular reports to external regulators as well as internal committees and leaders who have a vested interest in Appeal/Grievance monitoring. He/she will oversee the process required to ensure prepared for all internal review activities at any level, presentation/participation in Mass Board of Hearings, Independent Review Entity (IRE), or ALJ. The successful candidate will also help coordinate deliverables and lead A/G discussions to satisfy any internal or external audit requirements.

Responsibilities  

• Operational Leadership

·     Develop and implement policies and procedures that ensures the Appeals and Grievance function and its work products meet all compliance requirements

·     Ensure constant communication throughout all cross functional departments relative to any changes in A/G process, requirements, and performance

·     Provide oversight for complaints, A/G reporting and analysis, and interface with Member Services on ongoing key performance indicators

·     Oversee comprehensive A/G monitoring and integrate metrics monitoring across the enterprise to have a complete view of A/G activities and outcomes across all vendors, the Plan and delegated practices

·     Manage overall performance and productivity of the team and goals around quality and timeliness to meet contractual requirements, and facilitate interventions and coordination of actions by internal partners 

·     Oversee staff in their efforts to resolve and coordinate resources effectively to solve any needs for adhoc requests and ongoing projects relative to A/G, state and federal requirements

·     Provide guidance and leadership to the Appeal & Grievance manager/supervisor and frontline staff in processing complaint interventions and resolutions within the specified deadlines, data compilation, report completion, and data validation and audit preparation activities

 External Engagement with Regulators

·     Act as a liaison with State and Federal governments regarding the creation, submission and approval of materials for members and providers relative to A/G

·     Represent firms and A/G data and trends to external regulators when requested and at regularly scheduled programmatic meetings

·     Oversee internal or Level I review of appeals and support the coordination of participation in the Mass Board of Hearings and IRE and assure that relevant documentation is provided in advance

Education

Bachelor's Degree or equivalent experience, Master’s preferred.

Knowledge, Skills and Abilities

• Ability to accurately interpret contract language and regulations and develop policy, procedures and required materials for members and providers of a health care delivery and insurance plan

·     Staff management skills and experience

·     Budget management experience

·     Advanced skills with Word, Excel, and PowerPoint

·     Strong interpersonal skills and customer service orientation

·     Excellent verbal and written communication skills

·     Experience working with senior-level management

·     Strong ability to present to large groups, including regulators

·     Demonstrated leadership skills

·     Exceptional judgment in decision-making

·     Ability to meet tight deadlines through effective leadership and influencing others to produce results

·     Ability to work independently and with flexibility

·     Exceptional attention to detail is required for the position