The Director of Appeals & Grievances Performance Support is responsible for successful operation of several key functions in support of A&G; including regulatory reporting, analytics, root cause analysis, corrective action plan process, system/process implementations, vendor oversight activities, quality program activities, and audit readiness. This role works closely with multiple leaders in the organization to lead the quality program and identify priority focus areas for Appeals & Grievances, to standardize and optimize processes, and to communicate performance to multiple stakeholders. This role supports the activities that will foster A&G compliance and regulatory needs. In tandem with these efforts, this individual provides oversight to production support through reporting and systems to ensure the highest compliance and quality are maintained.
This position can work out of one of these locations: 100 Church Street, New York or Lake Mary, Florida
Duties & Responsibilities:
- Build and maintain repeatable and sustainable processes and procedures to ensure A&G inventory and production levels remain at the optimal level
- Ensure business process performance standards are defined, measured & documented. Execute delivery of a comprehensive quality program in support of this goal.
- Oversee and support production support staff activities both onshore and offshore.
- Deliver QA measurement results and orchestrate delivery of both operational and federal/state reporting needs for A&G teams
- Interpret, execute and recommend adjustments to policies, business processes, systems, and staffing to optimize business performance
- Ensure all phases of A&G processes remain compliant in aggregate and at the case level
- Consider vendor operations in day to day activities to ensure compliance with Healthfirst and A&G standards. Engage in regular communication with vendor partners to ensure production support activities being supported are in line with service level agreements and business needs.
- Recommend best practices and deploy approaches to performing Appeals & Grievances tasks
- Support staff education of all A&G practices, processes and protocols and that change is communicated and implemented appropriately.
- Develop an effective team through hiring, training, coaching and providing ongoing and constructive feedback
- Conduct regular department/unit/office meetings to inform staff of performance, results and new changes or issues. impacting the department and/or company
- Lead an audit support team to ensure A&G meets CMS & DOH regulatory requirements
- Maintain working relationships within operations areas to identify and execute overall process improvements
- Communicate A&G results and collaborate with operations areas to identify resulting process improvements
- Prepare and conduct monthly presentations to Senior Management on the unit’s performance and results
- Build partnerships with business areas 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 A&G team
- Support development of tools, documentation, and processes to assist in overall handling of A&G functions
- Lead and support operational and regulatory reporting needs, including orchestrating the delivery of CMS and state level A&G universes and reports.
- Lead and support new initiatives requiring A&G engagement
- Additional duties as assigned
- Bachelor's degree from an accredited institution or equivalent work experience
- Experience managing a team and leading work processes in a fast-paced environment
- Experience preparing and delivering information to multiple types of audiences
- Demonstrated ability to work well with others, understand process flows and correlating platforms, recommend options and implement solutions
- Work experience with process improvement initiatives
- Experience in supporting audits and regulatory requirements
- Experience communicating and influencing impact and progress to senior leadership
- 5+ years of healthcare appeals experience
- MBA or master's degree from an accredited institution with focus in training & development, education, business, or healthcare administration
- Six Sigma Black Belt
- Leadership experience in a focus area of audit, project management, or training design and delivery.
- Management experience in an operational department within the healthcare industry
- In-depth knowledge of the audit profession and auditing standards, policies and procedures
- 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
- Experience in A&G and federal/state requirement surrounding appeals and grievance processing
Compliance & Regulatory Responsibilities: Noted above
WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.
If you have a disability under the Americans with Disability Act or a similar law, and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to [email protected] or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.
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