Commonwealth Care Alliance Job Details: Manager of Appeals and Grievances in Boston, Massachusetts
Job Details: Manager of Appeals and Grievances
- Vacancy NoVN1567
Posting TitleManager of Appeals and Grievances
Language RequirementSpanish Preferred
This position is a major contributor to Commonwealth Care’s focus on member experience and customer service. The Manager of A/G provides oversight to staff who coordinate the end-to-end appeal and grievance process, ensuring compliance with all State and Federal regulatory requirements. The candidate will provide daily direction, communication, and support to the team to facilitate timely identification, intervention and resolution of the complaint intake and reporting processes for both the Senior Care Options (SCO) and One Care Programs.
In addition, this position coordinates the preparation of data and regular reports to external regulators as well as internal committees and leaders who have a vested interest in Appeal/Grievance monitoring. He/she will oversee the process required to ensure CCA is prepared for all internal review activities at any level, presentation/participation in Mass Board of Hearings, Independent Review Entity (IRE), or ALJ. The successful candidate will also help coordinate deliverables and lead A/G discussions to satisfy any internal or external audit requirements.
Develop and implement policies and procedures that ensures the Appeals and Grievance function and its work products meet all compliance requirements.
Ensure constant communication throughout all cross functional departments relative to any changes in A/G process, requirements, and performance.
Directs the activities of staff to appropriately research, review, interpret, and the subsequent implementation of current and new CMS and MassHealth guidelines and develop inter-departmental communications necessary to effectuate such changes.
Support the development of annual member materials to ensure A/G language meets CMS/EOHHS requirements.
Act as a liaison with State and Federal governments regarding the creation, submission and approval of materials for members and providers relative to A/G.
Manage the A/G staff responsible for reporting, data validation, and compliance with all requirements for CMS Chapter 13 and the EOHHS contracts.
Provides oversight for complaints, A/G reporting and analysis, and interface with Member Services on ongoing key performance indicators.
Oversee comprehensive A/G monitoring and integrate metrics monitoring across the enterprise to have a complete view of A/G activities and outcomes across all vendors, the Plan and CCA delegated practices.
Actively participate in work groups or committees within CCA as requested. Play a significant role in long-term planning, including strategic initiatives that fundamentally impact A/G processing, to include software selection/implementation, and support prioritization efforts.
Manage staff in their efforts to resolve and coordinate resources effectively to solve any needs for ad hoc requests and ongoing projects relative to A/G, state and federal requirements.
Responsible for managing overall performance and productivity of the team and goals around quality and timeliness to meet contractual requirements, and facilitate interventions and coordination of actions by internal partners.
Provides guidance and leadership to the Appeal & Grievance Representatives in processing complaint interventions and resolutions within the specified deadlines, data compilation, report completion, and data validation and audit preparation activities.
Represents CCA/CCC A/G data and trends to external regulators when requested and at regularly scheduled programmatic meetings.
Assure verbal and written responses are provided to members and/or providers within the required timeframes.
Oversee internal or Level I review of appeals and support the coordination of CCA’s participation in the Mass Board of Hearings and IRE and assure that relevant documentation is provided in advance.
Analyzes Data and Identifies trends for improvement purposes and staffing needs.
Communicates findings to leadership and other interested parties including staff working with third party vendors, such as the transportation and dental administrators.
Works collaboratively with clinical functions to support A/G review efforts, and works with their assigned specialty clinicians to coordinate decision-making.
Other functions as assigned by management.
Bachelor's Degree or equivalent experience, Master’s preferred.
2-4 years of experience working with CMS regulated A/G functions, and at least 1 year in a supervisory capacity.
Experience presenting complex clinical/confidential information to regulators.
Experience addressing complaints and turning negative experiences into positive outcomes.
Ability to accurately interpret contract language and regulations and develop policy, procedures and required materials for members and providers of a health care delivery and insurance plan.
Staff management skills and experience.
Budget management experience.
Advanced skills with Word, Excel, and Powerpoint.
Strong interpersonal skills and customer service orientation.
Excellent verbal and written communication skills.
Experience working with senior-level management.
Strong ability to present to large groups, including regulators.
Demonstrated leadership skills.
Exceptional judgment in decision-making.
Ability to meet tight deadlines through effective leadership and influencing others to produce results.
Ability to work independently and with flexibility.
Exceptional attention to detail is required for the position.
Please note employment with CCA is contingent upon acceptable professional references, a background check (including Mass CORI, employment, education, criminal check, and driving record, (if applicable)), an OIG Report and verification of a valid MA/ RN license (if applicable).
Commonwealth Care Allianceis an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.