Manager, Appeals and Grievances

HealthFirst•Lake Mary, FL

23h•Hybrid

About The Position

The Manager, Appeals & Grievances is responsible for leading, operating, and advising a dynamic and fast-paced Appeals & Grievances team. This role works closely with multiple leaders in the organization to identify priority focus areas for Appeals & Grievances, to standardize and optimize processes, and to communicate performance to multiple stakeholders. In tandem with these efforts, this individual will oversee Internal and external production teams to ensure consistent production, high quality and to maintain compliance on all levels. This role will remain flexible while utilizing strategic thinking and creativity to address challenges in alignment with long term growth and profitability goals of Healthfirst. Work Schedule This position requires three days per week in office (Tues/Wed/Thurs) at either: 100 Church St. New York, NY. or 1101 Greenwood Blvd. Lake Mary, FL.

Requirements

Bachelor's degree from an accredited institution or equivalent work experience
Experience with appeals and grievance processing and compliance
Experience building and managing a team and leading work processes in a fast-paced environment
Experience preparing and delivering written and verbal information to multiple types of audiences
Demonstrated ability to work well with others, understand process flows and correlating platforms, recommend options and implement solutions
Experience setting direction for department and managing staff performance
Experience managing multiple concurrent priorities.
Proven ability to work across areas in an organization to yield results

Nice To Haves

Extensive experience in the healthcare appeals experience
MBA or master's degree from an accredited institution with focus in training & development, education, business, or healthcare administration
Leadership experience in an focus area of operational excellence or audit
Management experience in an operational department within the healthcare industry focused on clinical leadership
Experience developing strategy and processes for a department or function
Experience managing vendors as an extension of a core team.
Familiar with creating accountable ownership of a vendor team

Responsibilities

Ensure management team is accurately monitoring performance through daily meetings, coaching, feedback, documentation and disciplinary actions in collaboration with the Intake Vendor.
Help Standardize and Optimize in how Appeals and Grievances are routed
Work with Providers and DSE on educating providers in how to submit Appeals timely and accurately.
Assist in leading the AOR / WOL Outreach team in coordination with the supervisor
Identify trends and recommend solutions for improvement.
Determine best practices and strategically deploy approaches to meet production, compliance and quality targets and to perform all Appeals & Grievances tasks
Manage, develop and engage team.
Work with leadership to establish and implement departmental goals, establish monthly goal review process and implement a plan of action for identified gaps
Maintain delegated vendor relationship and ensure vendor performance and compliance measures are met
Institute and manage working relationships within various operational areas to identify and execute overall process improvements
Build partnerships with business areas across and outside of operations to improve communication and responsiveness to multiple conflicting resource demands
Diagnose and understand operational challenges in addition to skill gaps in order to provide leadership and management to the Appeals & Grievances team
Focused on clinical criteria for expedited cases
Drive the development of innovative tools and processes to assist in overall handling of Appeals & Grievances functions
Working with the delegated vendor to identify opportunities to increase the rate in which SLA’s are met
Support use and updates of systems in place for delivery of quality of results
Maintain knowledge of industry trends, best practices and protocols.
Collaborate and share best practices with other units comprising the enterprise to ensure general consistencies and enhancements
Additional duties as assigned