job details

Job Number: 1222493
Job Title: Appeals & Grievances Manager
Job Type: Full-time
Location: New Hyde Park
Hours: 9-5
Post Date: Jun 11 2018
Salary: $90K-$100K
Detailed Job Description:
Oversees and directs the organizationâ??s grievance and appeals process to ensure the organization is compliant with state and federal regulatory and contractual guidelines. Directs and oversees the development, configuration and maintenance of data collection systems. Ensure the preparation and timely submission of data to regulatory agencies. Directs and oversees the preparation of reports and analysis for grievances and appeals to internal committees. Manages subcontractors; operations and regulatory compliance via oversight and audits.
Ensures appropriate processing-of member and provider appeals and grievances
Responds to request for State Fair Hearings, Department of Health (DOH), Complaint Tracking Module (CTM) complaints and any complaints filed through any other regulatory entity
Perform duties as the point of contact with the State in matters of appeals and grievances
Manage the day to day responsibilities of the Appeals and Grievances Coordinator(s)
Ensure that the Grievance and Appeals department investigates and processes all appeals and grievances in accordance with referred time frames and other contractual legal requirements
Monitor appeals and grievances to provide senior management with monthly reporting on trends
Required Skills:
Bachelors Degree, Masters a plus
Must have specific MLTC/Health Insurance A&G experience
Experience managing a team ideal
Exceptional skills in team building and managing staff in meeting/surpassing department goals
Exceptional leadership and interpersonal skills; able to effectively communicate and collaborate across all levels of the organizational structure
Experience in the health care industry
Knowledge of medical terminology
Strong customer service skills
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