Job Description

Position Purpose:  The Manager, Grievances, Disputes & Appeals oversees the daily activities of the grievances, disputes and appeals staff for the health plan(s) as well as the process of receiving, researching, and responding to formal provider claims disputes and member appeals.

 

Assure department efficiency and effectiveness:

·         Achieve financial objectives

·         Communicate job expectations to staff

·         Plan, assign, monitor, and appraise employee’s job results

·         Develop, implement, and enforce policies and procedures

·         Maintain, train, orient, mentor and evaluate staff

·         Set example of proper behavior and accountability to employees and serve as a role model for what is expected of a Health Choice employee

·         Hire, evaluate, counsel, and terminate staff within company guidelines

·         Ensure that department is appropriately staffed for health plan needs

·         Verify time cards of staff

·         Approve or deny requests for PTO and other time off requests

·         Provide staff with appropriate and updated resources as needed

  • Ensure that database and other recordkeeping resources are adequate and compliant for both the needs of the staff and the program requirements

Manage daily activities of Dispute/Appeals Department:

  • Effectively manage workflow of all employees
  • Ensure compliance to program timelines
  • Use database and reporting to monitor workflow
  • Develop forms or processes to ensure efficient workflow

Handles higher level cases:  

  • Assist staff in resolving disputes or appeals that need special attention or have a sensitive subject matter

Identify and report trends and solutions:

  • Use information gathered through the disputes and appeals process to report trends and analyze disputes, appeals, and/or hearings

Oversee reporting and documentation:  

  • Compose and submit reports of activity from the Disputes and Appeals Department
  • Compose and submit the required deliverables (reports) to contractor
  • Maintain Policies & Procedures and Desk Reference Materials, as required
  • Ensure program files are maintained for required period of time
  • Ensure files and other related documents are stored in most cost efficient setting, such as onsite and offsite storage


Qualifications

Education:   

·         High School Diploma or equivalent GED preferred

·         Associate’s degree (A.A.) or equivalent in Healthcare preferred

Years of Experience:  

·         At least two (2) years of management or supervisory experience

·         At least two (2) years of claims/billing or applicable AHCCCS experience preferred

·         Experience in legal preparation or proceedings preferred

Work Related Experience:  

·         Ability to do a verbal presentation

·         Ability to effectively supervise and lead 5-10 staff

·         Ability to think analytically and make decisions

·         Ability to manage large workload of varying tasks

·         Ability to maintain a positive work environment for employees

·         Handle multiple and changing priorities at a fast pace

·         Make independent decisions

·         Ability to manage multiple tasks and prioritize work tasks to adhere to deadlines and identified time frames

·         Computer experience necessary

·         Effective time management skills

·         Effective interpersonal and communication

Specialized Knowledge:  

·         Knowledge of the Administrative Law process helpful

·         Knowledge of legal environment helpful

·         Knowledge of Medicaid regulations and guidelines preferred

Application Instructions

To apply directly to Steward Health Care, please click the link below. Another window will open and allow you to apply directly online.

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