Director, Grievance and Appeals – Preferred Experience in Managed Care

This is a fully remote position, open to applicants in United States.

📋 Description

• Supervise the appeals and grievance processes.

• Lead the operational management of the appeals and grievance function, focusing on execution, results, ongoing improvement, and performance enhancement.

• Develop and implement processes, policies, training, and procedures to ensure adherence to regulations.

• Address performance issues and introduce mechanisms to enhance overall performance.

• Monitor and analyze preventable appeals and grievances, presenting findings to Operations leadership.

• Reduce legal and financial risks while safeguarding the interests of members and providers.

• Recognize when in-house legal assistance is necessary for sensitive cases.

• Collaborate with plan attorneys on litigated matters and assist in case preparation and research.

• Offer fiscal management and support, encompassing operating budgets, forecasts, and variance reporting.

• Ensure that systems and technology are adequate to support compliance, quality, and operational efficiency.

• Examine data to identify and implement process enhancements.

• Organize grievance and appeal committee meetings.

• Establish and nurture relationships with internal partners.

• Perform additional job responsibilities as assigned.

⛳️ Requirements

• A Bachelor of Science/Arts (BA/BS) or equivalent professional experience is mandatory.

• A minimum of five (5) years of management experience is essential.

• Experience in managed care is required.

• Direct leadership experience in a Healthcare operational G&A setting is necessary.

• A Master’s degree is preferred.

• Senior management experience is also preferred.

• Excellent customer service skills, with the ability to engage professionally and effectively with members, providers, internal business areas, and colleagues.

• Strong analytical abilities to create reports and interpret operational, utilization, and financial data.

• Demonstrated problem-solving skills with the capability to identify root causes and formulate actionable solutions.

• Proficiency in computers with experience in a Windows environment.

• Maintain knowledge of regulations to ensure compliance.

• Strong written and verbal communication skills are required.

• Ability to thrive in a fast-paced environment.

• Skills in decision-making and problem-solving are essential.

• No specific licensure or certification is required.

🏝️ Benefits

• A bonus linked to both company and individual performance may be offered.

• A comprehensive and substantial total rewards package is available.

• Support for employee total well-being is provided.