Hybrid Supervisor of Grievance & Appeals na Partnership HealthPlan of California
Partnership HealthPlan of California · Fairfield, Estados Unidos Da América · Hybrid
- Professional
- Escritório em Fairfield
Under direction of the Manager or above, provides supervision of the assigned Grievance staff, and assists in the day-to-day operations in the Grievance Unit by providing leadership, direction, and support to Lead Grievance Coordinators, Grievance Coordinators, and Grievance Resolution Specialists.
Responsibilities:- Supervises staff by providing leadership, direction, and support to Lead Grievance Coordinators, Grievance Coordinators, and Grievance Resolution Conducts regular meetings with grievance staff and provides performance feedback.
- Manages grievance staff schedules
- Monitors grievance staff calls to ensure consistency
- Maintains an internal auditing program that identifies key improvements and measures effectiveness and compliance with regulatory requirements for all assigned staff.
- Conducts annual performance evaluations for assigned Lead Grievance Coordinators, Grievance Coordinators, and Grievance Resolution Specialists.
- Leads grievance training program for onboarding of new grievance staff.
- Assists with the development of grievance staff training materials.
- Assists with the development of training materials for internal and external stakeholders.
- Reviews and provides guidance and interpretation to the Grievance and Appeals Resolution Manager on draft regulations and contract amendments related to Grievances.
- Participates in workgroups and projects that involve the identification and reporting of PQI, FWA, Privacy and Compliance issues discovered through the Grievance process.
- Participates in collecting, reviewing, and submitting materials and documents needed for internal and external audits.
- Participates in the collection and review of data as required for internal dashboards.
- Attends meetings on grievance system matters and prepares and distributes corresponding reports that track, trend, or analyze grievances.
- Assists with drafting, editing, or reviewing Grievance policies and procedures to ensure compliance with relevant state and federal requirements and/or industry standards.
- Participates in workgroups that address Grievance-system issues identified by stakeholders and through regular workflow.
- Drafts and/or edits internal auditing tools or templates used for grievance unit activities, including but not limited to those for grievances, appeals, and hearings.
- Conducts grievance unit internal audits to ensure quality and compliance with health plan and regulatory standards.
- Serves as resource to Grievance Unit and PHC staff on complex grievance, appeal, and/or state hearing cases.
- Assists with preparing cases for presentation to Grievance Review Committee, and coordinates completion of resolution actions with committee members.
- Participates in the oversight of delegated Grievance activities, including routine auditing to ensure compliance with PHC and/or regulatory standards.
- Maintains knowledge of current regulatory requirements under CMS and DMHC.
- Participates in NCQA accreditation activities.
- Periodically works with other department staff on assigned projects.
- Serves as back up to Lead Grievance Coordinators and/or Grievance Coordinators in the event of work overflow.
- Other duties as assigned.
All HealthPlan employees are expected to:
HIRING RANGE:
$93,690.86 - $117,113.58 IMPORTANT DISCLAIMER NOTICEThe job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change. | |||||||||
