Clinical Supervisor, Grievance and Appeals

Overview Supervises and monitors department clinical staff handling of grievances and appeals for all product lines, and ensuring compliance with state and federal regulatory requirements and timelines. Oversees and coordinates day-to-day business operations including monitoring internal processes, activities and collaboration between the clinical and non-clinical staff, and supervising support functions to facilitate efficient clinical operations and reviews. Maintains and ensures integrity of case files, system data and prepares data reports and analysis of appeals for program management and committees, as needed. Maintains current knowledge of state/federal regulatory requirements for each program. Identifies and recommends areas for improvement, staff education, develops and collaborates on training programs. Works under general direction. What We Provide Referral bonus opportunities Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays Health insurance plan for you and your loved ones: Medical, Dental, Vision, Life, Disability Employer-matched retirement saving funds Personal and financial wellness programs Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care Generous tuition reimbursement for qualifying degrees Opportunities for professional growth and career advancement Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities What You Will Do Supervises the day-to-day operations of VNS Health Plans Grievance & Appeals departments clinical and non-clinical staff. Makes recommendations to the development, utilization, and evaluation of internal processes to ensure customer satisfactions, efficient operations, and accurate and timely resolution of reviews related to appeals and grievances. Ensures the integrity of tracking logs and records documenting plan actions and timeframes for each case under review. Troubleshoots difficult cases or customer service issues, facilitates problem resolution and directs staff in addressing and resolving day-to-day operational issues. Maintains and supervises weekend work/on-call appeal processes. Tracks clinical grievances and appeals that are in process in the department, prioritizes workloads, workflow and execution of activities delegated to staff; directs/monitors/oversees resolution consistent with regulatory requirements, timeframes and VNS standards. Communicates with internal and external staff at all levels including but not limited to, Provider Relations, Utilization Management, Medical Directors, and/or, Care Management, to achieve resolution of appeals and grievances. Works with management in developing long and short-term objectives. Maintains readiness for DOH or CMS audit at all times. Ensures the accuracy and integrity of data collection and reporting systems to support analysis and reporting of grievances and appeals data for operations and for required CMS and DOH reporting. Assists and works with management as needed in analyses and reports on grievance and appeal activity for management, for committees and as required by regulation; analyzes trends and recommends departmental improvements. Supervises and tracks appeals external to the plan including cases with the CMS independent review entities and NYS Fair Hearings and External Appeals. Supervises investigations and prepares a recommended responses to clinical appeals and grievances referred to the plan from regulatory entities including but not limited to the Department of Health, CMS and Department of Insurance. Assists with identifying and addressing trends or process gaps. Assists in the development and implementation of policies, procedures and operational workflows related to grievances and appeals. Recommends and assists in the development of standards and criteria for monitoring compliance with regulatory requirements for all VNS Health product lines. Monitors and analyzes process flow for timeliness and efficiencies across all programs. Stays abreast of changes to Medicaid and Medicare regulations. Identifies and recommends changes to plan grievance and appeal operations accordingly. Serves as a resource on grievances, appeals and external reviews. Identifies and recommends key areas for training and coaching of staff based on departmental monitoring and oversight. Maintains and oversees staff leave schedules, ensures adequate staff coverage for departmental functions year-round, and holiday and weekend coverage. Performs all duties inherent in a supervisory role. Ensures effective staff training, evaluating staff performance, recommends hiring, salary actions, promotions, terminations and performs orientation/training to facilitate the professional growth and development of assigned staff. Participates in special projects and performs other duties as assigned. Licenses and Certifications License and current registration to practice as a Registered Professional Nurse in New York State required Education Bachelor's Degree in Nursing or other related degree for Registered Nurses required. Master's Degree in public health or health-related field preferred Work Experience Minimum of three years experience in health care required Minimum of two years experience with Grievance and Appeals in a Medicare and/or Medicaid managed care setting required. Experience in a supervisory role preferred Excellent oral and written communication skills required Computer literacy including word processing, spreadsheet applications, and database applications required. Experience with MS Office preferred Pay Range USD $98,200.00 - USD $130,800.00 /Yr. #J-18808-Ljbffr