Responsible for management oversight of receipt, investigation and processing associated with grievance and appeals ensuring regulatory compliance, quality, manages inventory and production levels, and operational and plan risk.
Location: This position will work a hybrid model (remote and office) and must live within 50 miles of our Latham, New York Pulse Point office location.
How will you make an impact:
Serves as a functional resource expert and mentor to unit and other departments 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.
May perform internal audits of grievance and appeals process.
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.
Hires, trains, coaches, counsels, and evaluates performance of direct reports.
Minimum requirements:
Requires a bachelor's degree and a minimum of 3 years leadership experience in grievance & appeals, claims or customer services 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.
If this job is assigned to any Government Business Division entity, the applicant and incumbent fall under a 'sensitive position' work designation and may be subject to additional requirements beyond those associates outside Government Business Divisions.
Requirements include but are not limited to more stringent and frequent background checks and/or government clearances, segregation of duties principles, role specific training, monitoring of daily job functions, and sensitive data handling instructions. Associates in these jobs must follow the specific policies, procedures, guidelines, etc. as stated by the Government Business Division in which they are employed.
