Manager Grievance & Appeals (Provider Services)
CalOptimaCalOptima Health is seeking a highly motivated an experienced
Manager, Grievance & Appeals (Provider Services) to join our team. The Manager Grievance & Appeals (Provider Services) will provide daily oversight and technical management for provider services, including provider disputes, provider grievances and provider appeal to ensure compliance with state, federal and accreditation standards applicable to CalOptima Health. The incumbent will work with CalOptima Health management staff and other affiliated health networks with a close interface to the program and process, including areas such as Utilization Management, Claims Administration, Delegation Oversight, Quality Improvement and health network relations. The incumbent will research complex claims problems, isolate root causes and partner with various entities for resolution. The incumbent will communicate with all levels of internal staff, regulatory agencies, health networks, providers, vendors, community‐based organizations and medical groups.
Position Information: - Department: GA ‐ Provider Disputes
- Salary Grade: 315 ‐ $109,892 ‐ $175,827 ($52.83 ‐ $84.5322)
- Work Arrangement: Partial Telework
**This position is eligible for telework in California.**
Duties & Responsibilities: - 50% ‐ Program Oversight
- Identifies and analyzes trends, collaborates with the Director to provide trends and makes recommendations for improvement.
- Stays current on the local, state and federal health care environment, identifying issues that may impact CalOptima Health's programs as they relate to claims, provider disputes, grievances and provider appeals.
- Develops, implements, maintains and reviews the adequacy of the CalOptima Health provider grievance systems, reporting, policies and functions to achieve stated goals, including, but not limited to, complaint resolution and timely responsiveness for all lines of business, to ensure compliance with all relevant regulatory requirements pertaining to provider disputes.
- Works with the Audit and Oversight department and key departments to ensure internal departments and external partners (e.g., health networks and delegates) are up to date with regulatory, departmental and organizational changes impacting the grievance and appeals processes.
- Ensures timely and effective data collection, summarization, integration and reporting, including, but not limited to, productivity, status and trend reports for specific committees such as the Quality Improvement Committee, Grievance and Appeals Committee, Quality Assurance Committee of the Board of Directors and other ad hoc reporting as required.
- Serves as CalOptima Health's primary point of contact and subject matter expert related to provider services (disputes, grievances and appeals).
- Participates in Department of Managed Healthcare (DMHC), Department of Health Care Services (DHCS) and Centers for Medicare and Medicaid (CMS) audits related to area of responsibility for all CalOptima Health programs.
- 45% ‐ Leadership
- Cultivates and promotes a mission‐driven culture of high‐quality performance, with a member focus on customer service, consistency, dignity and accountability.
- Directs and assists the team in carrying out department responsibilities and collaborates with the leadership team and staff to support short‐ and long‐term goals/priorities for the department.
- Manages, hires, mentors and develops department staff.
- Oversees the development and maintenance of internal policies and procedures and desktops to ensure compliance with all state and federal regulations for multiple lines of business.
- Manages and makes recommendations on the development and maintenance of an effective dispute, appeals and grievance process and systems consistent with CalOptima Health policies and stated goals, including, but not limited to mechanisms to monitor provider disputes, grievances and appeals involving Legal, DMHC, DHCS, Independent Medical Review, Medi‐Cal State Hearings, Office of Administrative Hearings and Appeals, CMS and external review agencies for CMS.
- Partners with the management to ensure appropriate training and auditing tools are developed and maintained for the department.
- 5% ‐ Other
- Completes other projects and duties as assigned.
Minimum Qualifications: - Bachelor's degree in business administration, nursing, healthcare administration or related field PLUS 3 years of health care management experience in a related area of responsibility (provider disputes and appeals, claims administration, appeals and grievances) required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.
- 3 years of leadership experience required.
- Experience in health maintenance organization, Medi‐Cal/Medicaid, Medicare Advantage, Medicare Part D, Special Needs Plans, Medicare‐Medicaid Plans and/or the Program of All‐Inclusive Care for the Elderly required.
Preferred Qualifications: - Experience with process improvement implementation.
Required Licensure / Certifications: Knowledge & Abilities:
- Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds.
- Work independently and exercise sound judgment.
- Communicate clearly and concisely, both orally and in writing.
- Work a flexible schedule; available to participate in evening and weekend events.
- Organize, be analytical, problem‐solve and possess project management skills.
- Work in a fast‐paced environment and in an efficient manner.
- Manage multiple projects and identify opportunities for internal and external collaboration.
- Motivate and lead multi‐program teams and external committees/coalitions.
- Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.
Physical Requirements (With or Without Accommodations): - Ability to visually read information from computer screens, forms and other printed materials and information.
- Ability to speak (enunciate) clearly in conversation and general communication.
- Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face‐to‐face interactions.
- Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.
- Lifting and moving objects, patients and/or equipment 10 to 25 pounds
Work Environment:
