HealthSun Health Plans www.healthsun.com is seeking energetic,talented and qualified professionals to join us in our mission of changing the healthcare experience of our members - making it easier, friendlier and more accessible. If you are looking for a challenging and rewarding career with a chance to make a real difference in your community, please apply.
HealthSun Health Plans is headquartered in the Coconut Grove area of Miami, Florida supporting the needs of Medicare Advantage recipients throughout South Florida. We are proud to offer outstanding career advancement opportunities, competitive salaries, paid holidays, medical & dental insurance plans, Paid Time Off, disability benefits, and a 401(k) retirement savings plan.
The Grievance & Appeals Manager is responsible for managing the timely and accurate processing of all Medicare Part C and Medicare Part D grievance and appeals related activities.
Essential Duties & Responsibilities:
- Demonstrate a solid understanding of the appeals and grievance process, including all regulatory requirements to ensure department compliance with CMS.
- Assists staff with researching claims, authorizations/referrals, contracts, and medical records reviews to ensure completeness of case work.
- Ensures staff responses to complaints, grievances and appeals in a consistent fashion, adhering to all regulatory, accreditation and internal processing timelines and guidelines
- Appropriates communications within all parties, including but not limited to verbal communications and use of approved letters and notices.
- Reviews and implements all new ODAG and CDAG requirements.
- Responsible for Part C and Part D Appeal and Grievances reporting requirements.
- Implements process improvement.
- If summoned, participates in Administrative Law Judge Hearings, Judicial Hearings and MAC Hearings.
- Maintains appropriate and up to date knowledge of Appeals and Grievance guidelines established by the CMS and working knowledge of Medicare regulations in general.
- Identifies any trends or issues of concern and addresses them with the Grievances and Appeals Committe and/or Medicare Compliance Officer.
- Serves as the key contact for any Medicare outside entity (MAXIMUS Federal Services, ALJ, Judicial Review, MAC).
- Establishes and document processes, policies, procedures and workflows to support compliant and timely handling of appeals and grievances. Create and implement any necessary corrective action plans to bring areas of non-compliance into compliance.
- Develops and manages reporting to monitor key performance indicators, identify trends, conduct root cause analysis, report to appropriate committees, and adhere to regulatory reporting requirements.
- Maintains strong working relations with all internal and external parties.
- Guides all other the Appeals and Grievance team members with any concerns or questions that relates to the appeals/grievance process.
- Handles escalated calls and assist with the resolution process.
- Assists with reporting, projected planning or process improvement plans.
- Helps monitor the grievance and appeal logs and ensure all compliance components are met.
- Meets with COO on a regular basis to:
- Provide feedback on departmental and staff issues/opportunities
- Staffing requirements and needs
- Receive feedback on own performance
- Reviews overtime report and ensures communication with staff as appropriate.
- Communicates effectively with other professional and support staff in order to achieve positive customer outcomes.
- Promotes and contributes to a positive, problem-solving environment.
- Assists customers, family members and others with concern and empathy; respect their confidentiality and privacy and communicate with them in a courteous and respectful manner.
- Accomplishes call center human resource objectives by recruiting, selecting, orienting, training, assigning, coaching, counseling, and disciplining employees; administering scheduling systems; communicating job expectations; planning, monitoring, appraising, and reviewing job contributions; planning and reviewing compensation actions; enforcing policies and procedures.
- Complies with company policies and procedures and maintains confidentiality of customer medical records in accordance with state and federal laws.
- Ensures compliance with all HIPAA, OSHA, and other federal, state, and local regulations.
- Participates in meetings, training and in-service education, as required.
- Performs other duties as assigned.
Qualifications & Education:
- Bachelor's degree in Health Care Administration or related field from an accredited college or university preferred
- Minimum of 3 - 5 years of managed care experience required
- Minimum of 1 year experience working in grievance and appeals or compliance related to Medicare and/or Medicaid required
- Prior experience working in a managed care call center environment preferred
- Minimum of 2 years in a demonstrated leadership or management role required
- Excellent computer knowledge is required, including proficient knowledge of Microsoft Office
- Analytical thinker, able to strategize plans based on data and metrics
- Ability to identify, prioritize and rectify problems systematically
- Ability to work, learn and implemented approve solutions independently
- Excellent listening, interpersonal, verbal and written communication skills with individuals at all levels of the organization
- Must be patient in dealing with an elderly population and sympathetic to hearing or vision deficiencies
- Ability to work effectively independently and in a team environment
- Ability to read, analyze, and interpret technical procedures or governmental regulations
- Ability to write reports, business correspondence, and procedure manuals
- Ability to effectively present information and respond to questions from groups of managers, clients, customers and the general public
- Ability to define problems, collect data, establish facts, and draw valid conclusions
- Must be self-motivated, organized and have excellent prioritization skills
- Must be able to work well under stressful conditions
- Must be able to work in a fast paced environment
- Fluency in Spanish and English required
HealthSun Health Plans and its affiliated companies is an equal opportunity/affirmative action employer and complies with all federal and state laws, regulations and executive orders regarding affirmative action requirements in all programs.M/F/D/V.
HealthSun and its affiliates are also a drug-free workplace.
*Internal candidates must submit the Internal Application Form approved by his/her supervisor before interviewing with HR. Qualified candidates will be considered by the Hiring Manager.