Director, Grievance and Appeals – Preferred Experience in Managed Care

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🔥 1 minute ago

🇺🇸 United States – Remote

💵 $113k - $197.7k / year

⏰ Full Time

🔴 Lead

👔 Director

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CareSource

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 30+ years

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

CareSource is a health services company focused on providing affordable health insurance and healthcare solutions. It offers a wide range of plans including Medicaid, Marketplace, and Medicare Advantage, targeting low-income adults, families, children, pregnant women, elderly adults, and people with disabilities. Additionally, CareSource provides members with resources for COVID-19 support, dental, vision, and hearing benefits, as well as pharmacy services. The company emphasizes easy access to healthcare management through online platforms and a mobile app.

📋 Description

• Oversee appeals and grievance processes • Direct efficient operational management of the appeals and grievance function, emphasizing execution, outcomes, continual improvement and performance enhancement • Design and implement processes, policies, training and procedures to ensure compliance with regulations • Address below-standard performance and implement mechanisms to improve performance • Track and trend preventable appeals and grievances and present findings to Operations leadership • Minimize legal and financial risk while protecting the interests of members and providers • Identify the need for in-house legal involvement on sensitive cases • Coordinate with plan attorneys on litigated cases and help oversee case preparation and research • Provide fiscal management and support, including operating budgets, forecasts and variance reporting • Ensure appropriate systems and technology support compliance, quality and operational efficiency • Analyze data to identify and implement process improvements • Coordinate grievance and appeal committee meetings • Establish and maintain relationships with internal partners • Perform other job duties as requested

🎯 Requirements

• Bachelor of Science/Arts (BA/BS) or equivalent years of work experience is required • Minimum of five (5) years of management experience is required • Managed care experience is required • Direct leadership experience in a Healthcare operational G&A environment is required • Master’s degree is preferred • Senior management experience is preferred • Customer service skills with the ability to interact professionally and effectively with members, providers, internal business areas and colleagues • Strong analytical skills with the ability to create reports and interpret operational, utilization and financial data • Proven problem-solving skills with the ability to identify root causes and develop implementable solutions • Computer proficiency with knowledge and experience in a Windows environment • Maintain regulatory knowledge for compliance • Strong written and verbal communication skills • Ability to work in a fast-paced environment • Decision-making and problem-solving skills • No licensure or certification required

🏖️ Benefits

• Bonus tied to company and individual performance may be available • Substantial and comprehensive total rewards package • Employee total well-being support

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