Appeals and Grievances Team Leader- Remote

The purpose of this position is to provide lead level support to the Appeals and Grievances team with the direct assistance of the Director of Claims Operations. The purpose of the position includes overseeing the processing, tracking, and following up on all medical necessity and administrative denials, appeals, grievances, and disputes for Medicare Advantage members in accordance with Medicare guidelines and regulations. The Appeals and Grievances Team Leader is a critical team player who works in a fast-paced, ever-changing environment with a passionate team and must deliver daily. ESSENTIAL FUNCTIONS: To perform this job, an individual must perform each essential function satisfactorily with or without a reasonable accommodation. Capture, investigate and respond to all complaints regarding customer grievances and appeals in addition to overseeing claim payment disputes provision of service and benefit coverage issues Conduct pertinent research to evaluate, answer, and close appeals Ensure appropriate resolution to inquiries, grievances and appeals within specified timeframes established by either regulatory/accreditation agencies or customer needs; ensure appropriateness of the response in compliance with State and Federal guidelines Assist members when filing appeals; educate members, document and route the information appropriately Prepare response letters, notifications, and acknowledgements for members and provider complaints, grievances and appeals Maintain grievance information and supporting documentation in accordance with all state, federal, NCQA, URAC and other regulatory agency standards / regulations Escalate issues appropriately or work with other departments to resolve member issues Ensure all HIPAA and State requirements/regulations are always adhered to Identify issues and root causes of appeals and disputes for plan management and compliance Identify and report trends and/or areas of opportunities to supervisor Maintain and update appeal and grievance policies and procedures, member correspondence materials, and process manuals Perform internal audits of grievance and appeals process Maintain privacy and confidentiality of records, conditions, and other information relating to residents, employees and facility Encourage an atmosphere of optimism, warmth and interest in patients’ personal and health care needs Meet critical time frames on a frequent and regular basis Required Skills: Excellent communication skills and active listening Positive, engaging customer service skills Meet critical time frames on a frequent and regular basis Work cooperatively with internal departments and external stakeholders Perform in potentially stressful situations, such as state, federal, NCQA, URAC or other regulatory/accrediting agency audits Required Work Experience: Minimum (3) three years’ health plan experience; insurance, compliance, managed care, or quality assurance preferred Minimum (3) years of Grievance and appeals experience preferred, specifically within a Medicare and/or Medicare Advantage context Minimum two years of demonstrated leadership skills in claims and/or appeals and grievances Proven track record for improving processes and problem-solving skills Ability to motivate team members while also possessing strong leadership skills Experience working with physicians and clinicians in the appeals and grievance space, preferred Knowledge and understanding of complaint and appeal procedures Knowledge of managed care, particularly utilization management processes Knowledge of NCQA, HEDIS or general accreditation requirements and guidelines for utilization management, denials and appeals Familiarity with Appeals processes and regulatory requirements related to Customer service experience Proven ability to problem-solve and make solid and well-researched decisions Qualifying criminal background Education Requirements: High school diploma required Associates degree preferred Successfully completed college courses in relevant fields to compensate for experience preferred Medicare experience preferred Apply To This Job