About Clever Care Health Plan
Clever Care Health Plan is a newly founded Medicare Advantage health plan, will serve Medicare beneficiaries in Southern California. Our employees are passionate in providing best services to our members and healthcare providers. Two office locations are at Arcadia, Los Angeles county and Westminster, Orange county.
This position will be based in Arcadia, CA.
The Appeals and Grievances Supervisor will oversee the intake and resolution process for member grievances, appeals and provider disputes, ensuring CMS compliance and NCQA standards and with the State and other mandated guidelines. The Grievance & Appeals Supervisor works within thorough, prescribed guidelines and procedures; uses independent judgment requiring analysis of variable factors to solve intermediate problems; collaborates with management and top professionals/specialists in selection of methods, techniques, and analytical approach. Development of policies, procedures, processes and front line staff practices to ensure contract compliance.
Functions & Responsibilities
- Maintains and coordinates staff activities to achieve departmental and corporate goals to improve service to customers/providers and assures regulatory compliance.
- Ensures consistency in execution across team. Holds team members accountable for following established policies.
- Hires, trains, coaches, counsels, evaluates performance of direct reports, and other duties as assigned.
- Create job aids and assist to maintain desk level procedures.
- Implements education strategies targeted at member orientation, retention, wellness, HEDIS measures, and to reduce member grievances and appeals.
- Addresses customer, provider, and other departments needs and concerns related to the Appeals and Grievances department.
- Prepares appeal summaries, correspondence; and documents information for tracking/trending data; assists in the preparation of narratives, graphs, flowcharts, etc. for presentations and audits.
- Perform focused quality sampling audits and report findings to management.
- Maintain familiarity and compliance with federal, state and local regulations as well as other regulatory requirements (e.g. NCQA standards) relative to appeal and grievance operations.
- Identify and report trends seen in grievances, appeals, and medical records to management.
- Validates integrity and accuracy of data outputs for Grievance and Appeals reporting.
- Prepare reports for presentation at various committees (e.g. Medical Services Committee, Executive Board Meetings, Compliance Committee, etc.,) as requested.
- Provide exceptional customer centric interactions with other departments.
- Assist customers in a caring and knowledgeable manner, representing the organization as a skilled health professional.
- BA/BS preferred
- 3+ years previous experience working in Grievance and Appeals/Utilization Management.
- 2+ years of management experience in the healthcare industry
- Ability to work in a fast paced environment with changing priorities
- Knowledge of healthcare industry coding theory, rules and standards (CPT, HCPCS, Revenue, ICD9, DRG, etc).
- Knowledge of CMS regulations related to Grievance & Appeals.
- Ability to ensure organizational compliance with all required rules, policies, and procedures.
- Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
- Results oriented
- Ability to perform analysis and apply sound reasoning in problem solving
- problem solver.
- Intermediate knowledge of Microsoft Word, Excel and beginner knowledge in Microsoft PowerPoint
Job Type: Full-time
- 401(k) matching
- Dental insurance
- Health insurance
- Paid time off
- Vision insurance
- 8 hour shift
- Monday to Friday
- Management: 2 years (Preferred)
- Utilization Management: 3 years (Preferred)
- Grievance and Appeals: 3 years (Preferred)
- healthcare industry: 3 years (Preferred)
- United States (Preferred)
- Waiting period may apply
- Only full-time employees eligible
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