Team Lead, Grievance & Appeals

Job Summary:The Team Lead, Grievance and Appeals oversees the day-to-day performance of grievance and appeals specialists, while ensuring all regulatory, compliance and HIPAA guidelines are met for Medicaid, Medicare and the Massachusetts Market.Essential Functions:Supervise staff for quality review, performance feedback, disciplinary issues and merit/bonus appraisal reviewMeet all monthly, annual and semi-annual reporting deadlinesWork with Regulatory Compliance Officers to ensure that requests are resolved within time lines and tracked for reportingMonitor Medicaid and Medicare processes to ensure that all regulatory requirements are followedWork with support departments and compliance officers to ensure policies and procedures are currentEstablish an audit processResponsible for evaluating operations and identifying process improvement needs. Identify irregular trends with grievances and appeals; work with other areas as appropriate to identify root causes and appropriate steps for resolutionResponsible for staffing, ensure that open positions are filled, and evaluate future staffing needsReview validation reports to ensure that grievances and appeals are accurateDevelop and monitor workflows for Grievance and Appeals Department that ensures maximum level of productivityMonitor member-facing departments to ensure that grievances and appeals are resolved and reported to the Grievance and Appeals DepartmentConduct audits and provide feedback to all areas that submit grievances and appealsFacilitate timely resolution of member and provider issues.Ensure that Grievance and Appeals Specialists are available to respond to incoming callsCoordinate incoming information and disseminate to staff to ensure accuracy of communication to internal and external customers.Create, review, revise and enforce company and departmental policies and proceduresAct as the contact point for CareSource on operational issues to all regulatory bodies in existing and future lines of businessActively interact with IT department for immediate problem resolution and for coordination of data transmissionsProactively keep the management team apprised of the team’s performance, projects and issuesProvide support to the Service Center during high call volume or other support as neededDevelop, deliver or coordinate the delivery of grievance and appeals training to other areas as needed.Perform any other job related instructions, as requestedEducation and Experience:Associates Degree or equivalent years of relevant work experience requiredMinimum of three (3) years of customer service experience in an HMO or related industryPrevious supervisory/leadership experience preferredCompetencies, Knowledge and Skills:Basic computer skills including Microsoft Word, Excel and PowerPointBasic experience with ACD systemsBasic experience with Call Management SystemsCommunication skillsPrior supervisory skillsAbility to work independently and within a team environmentAttention to detailFamiliarity of the healthcare field and knowledge of MedicaidCritical listening and thinking skillsTraining/teaching skillsStrategic management skillsNegotiation skills/experienceProper grammar usageTechnical writing skillsTime management skillsProper phone etiquetteCustomer service orientedDecision making/problem solving skillsStrong language skillsAbility to write comprehensive statements using proper grammar and sentence structureLicensure and Certification:NoneWorking Conditions:General office environment; may be required to sit or stand for extended periods of timeCompensation Range:$62,700.00 - $100,400.00CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.Compensation Type (hourly/salary):SalaryOrganization Level CompetenciesFostering a Collaborative Workplace CultureCultivate PartnershipsDevelop Self and OthersDrive ExecutionInfluence OthersPursue Personal ExcellenceUnderstand the BusinessThis job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.Brand=CareSourceOriginally posted on Himalayas