Innovative Integrated Health Community Plans
WHO WE ARE:
IIH Community Plans is a mission-driven health plan serving Medicare beneficiaries in California. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.
By becoming a part of the IIH Community Plans team, you will provide members with the quality of care they deserve. We believe that great work comes from people who are inspired to be their best. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In our rapidly growing company, you will find ample room for growth and innovation.
Responsibilities:
The Grievances and Appeals Resolution Services (GARS) Manager is responsible for the daily operations of the GARS department and supervision of staff. This position will provide necessary training and guidance to the staff as needed, and will work closely with compliance and audit teams to identify training opportunities, patterns, and trends from the complaints and opportunities to streamline and improve processes. The incumbent will inform leadership of findings.
The GARS Manager is responsible for staying up to date on the latest information about IIH Community Plans’ member benefits and regulatory changes and ensuring adherence to established policies and procedures regarding the grievances and appeals processes. This position will be responsible for developing and implementing a staffing plan for the GARS department and will provide leadership, training and guidance to staff as needed. (Note: IIH Community Plans is a start-up entity and the incumbent will initially be expected to function as an individual contributor. Additional staff may be hired as the plan grows.)
Duties include, but are not limited to:
- Essential duties and responsibilities include but are not limited to:
- Supervises and manages the performance of the Resolution Specialist and/or Program Assistant teams
- Monitors team performance and trends, and coaches’ staff to ensure adherence to policies, procedures, and the highest level of customer service
- Manages case inventory to ensure regulatory and departmental standards are met
- Writes and delivers job performance evaluations for staff, responsible for the professional and performance development of the staff
- Assists in the hiring process and provides ongoing staff training as needed
- Handles escalated member or provider cases/calls as needed
- Responsible for prompt communication with staff; conducts regular department meetings to review any changes to programs or training issues
- Facilitates one-on-one meetings with staff to review monthly progress regarding performance
- Sets or recommends work performance standards; collaborates with staff to determine assignment priorities
- Reviews work procedures and recommends or changes procedures to improve efficiency
- Recognizes and resolves problems impacting department processes by collecting and analyzing information; communicates suggestions to management and develops/implements solutions as appropriate
- Attend and participate in staff meetings, in-services, projects, and committees as assigned.
- Adhere to and support the center’s practices, procedures, and policies including assigned break times and attendance.
- Accept assigned duties in a cooperative manner; and perform all other related duties as assigned.
- Be flexible in schedule of hours worked.
- May require use of personal vehicle
Competitive Benefits and Salary:
- Desirable work schedule
- Health Insurance Coverage (Medical, Dental and Vision)
- 401K
- Paid time off (including holidays, vacation and sick time)
- Competitive Salaries and bonuses
- Recruitment Referral Bonus Program
- Professional development opportunities
- Employee Recognition events and activities
- Please contact Human Resources for salary information
Location: Central Valley area (Fresno, Tulare, Kern counties), CA; or any remote location within California
. Requirements:
- Bachelor’s degree in Business Administration, Health Administration or related field
- Minimum of three (3) years of health care experience in a managed care environment in related areas of responsibility of Utilization Management, Quality Management, Customer Service, and/or Grievances and Appeals required
- Minimum of three (3) to five (5) years of Supervisory or Lead work experience
- Minimum of three (3) to five (5) years of management experience in a health maintenance organization (HMO); Medicare, Medi-Cal/Medicaid and health care services experience preferred
- Experience with Medicare claims billing guidelines (i.e., Health Care Financing Administration (HCFA) 1500, Universal Billing (UB) 92, Coordination of Benefits (COB), including Current Procedural Terminology (CPT), ICD-10 and Healthcare Common Procedure Coding System (HCPCS)) preferred
- Experience in Medicare regulatory guidelines for Organizational Determinations Appeals and Grievances (ODAG) reporting
- Bi-lingual (English/Spanish) strongly preferred
- Medicare and Medi-Cal program regulations, including State and Federal standards and regulations for member and provider rights and responsibilities
- Principles and practices of the managed health care systems, and medical administration and National Committee Quality Assurance (NCQA) Accreditation standards
Source: Indeed.com
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