Manager, Appeals & Grievances

Job description

JOB DESCRIPTION Job Summary Leads and manages team responsible for claims activities including reviewing and resolving member and provider complaints, and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid Services (CMS). Essential Job Duties: - Manages team responsible for the submission/resolution of member and provider appeals and grievances; ensures resolutions are compliant with applicable standards and requirements. - Assesses and audits business processes to determine effective and efficient resolution of member and provider grievances. - Serves as primary interface with stakeholders and business partners, and ensures standard processes are implemented. - Oversees preparation of narratives, graphs, flowcharts, etc. to be used for committee presentations, audits and internal/external reports; oversees necessary correspondence in accordance with regulatory requirements. - Ensures claims production standards set by the department are met. - Maintains call tracking system of correspondence and outcomes for provider and member appeals/grievances; oversees/monitors...