The Supervisor of Appeals & Grievances is accountable for the recruitment, hiring, promotion, counseling, and daily supervision of Grievance and Appeals Specialists and administrative support as they receive, investigate and resolve member complaints, member grievances, and provider disputes. This position is also responsible for the coordination of the resolution of grievance situations requiring competent and effective resolution in compliance with legal and regulatory requirements. This position will also perform initial and ongoing training in necessary skills and knowledge base and will assist Manager of Grievance and Appeals to establish and maintain procedures for Unit to maximize both outcomes and operational efficiency.
Essential Duties & Responsibilities
Provides daily supervision for Grievance and Appeals Unit, including coordination of backup staffing, cross-training and deployment.Performs recruiting, hiring, promotion, and performance evaluation tasks and counsels non-clinical Grievance and Appeals staff.Orients and trains new Grievance and Appeals Unit members.Continually trains Unit members concerning grievances, appeals, and provider disputes/appeals.Regularly audits work of G&amp;amp;amp;amp;amp;amp;A Specialists and reports results.Coordinates investigation and resolution of complex appeal and grievance issues.Provides approval decisions involving grievance and appeal determinations.Coordinates maintenance and updates of desktop procedures and manuals for Unit.Assists in the establishment of grievance operating procedures.Prepares reports as required and performs trend analyses.Participates in Health Plan audits as needed.Performs other related duties as required.
- Bachelor's Degree or equivalent
Government Clearance & US Citizenship Requirement
Minimum five years experience in Managed CareTwo years supervisory experience preferredORAny combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position.
Knowledge, Skills & Abilities
Excellent written and verbal skills, with the ability to write complex letters and reports and make effective verbal presentationsAbility to effectively interact with both internal and external customers and G&amp;amp;A team membersExcellent professional research, analysis and problem solving skillsComputer skills including working knowledge of Microsoft Word, Excel, and Access; familiarity with PowerPoint desiredThorough knowledge of Health Net benefits, contract language, eligibility, internal operations, and policies and procedures
- The following section describes the general physical requirements for this position. Please note that constant refers to more than 81% of time; significant refers to 40-80%; and moderate refers to 20-40% of the time.
- Operates personal computers, printers, facsimile, telephones, copy machines and other commonly used office accessories/equipment.
- Exposed to confidential information and expected to maintain confidentiality at all times; must adhere to HIPAA rules and regulations.
- May be required to work outside of normally scheduled hours as mandated by the client, project and/or workload (e.g. evenings, weekends, and/or holidays)
- May be required to maintain established work pace, meet deadlines; may have last minute urgent requests.
- Physical activity may include: twisting, reaching, kneeling, bending, stooping, squatting, crawling, grasping, grabbing, pushing, pulling, repetitive motion, climbing, etc.
- Required to have visual acuity to determine the accuracy, neatness, and thoroughness of the work assigned.
- Required to have hearing ability to receive detailed information through oral communication
- Required to have speaking ability to express or exchange ideas.
- Constant concentration may be required on various subjects by listening, reading and thinking clearly.
- Interaction with others may be required. May need to listen, think, and speak in order to interact with others. Business interactions and behavior between coworkers and/or external customers are required. This may require face-to-face or telephone interactions.
- Thinking at work may include listening, learning, analyzing, evaluating, and the ability to interpret what is seen and/or heard, or to link information from one issue to the next.
- Constant computer usage including typing and/or eye strain.
- Moderate phone usage; headsets may be required.
- Significant amount of time spent working in a loud office environment with frequent interruptions/distractions.
- Constant sedentary work (desk bound or seated).
- Constant reading is required via computer screen and/or bound printed materials.
DISCLAIMER: The above statements are intended to describe the general nature and level of work being performed by individuals assigned to this job. They are not intended to be construed as an exhaustive list of responsibilities, duties and skills required of personnel so classified.
Location : Woodland Hills, CA
Health Net, Inc. supports a drug-free work environment and requires
pre-employment background and drug screening.
Health Net and its subsidiaries are an Equal Opportunity/Affirmative Action
Employer - Minorities/Females/Veterans/Disability
About Health Net, Inc.
Health Net, Inc. (Health Net) is an integrated managed care organization that delivers managed healthcare services through health plans and government-sponsored, managed-care plans. The Company operates and conducts its businesses through its subsidiaries. Health Net's health plans and government contracts subsidiaries provide health benefits through its health maintenance organizations (HMOs), insured preferred provider organizations (PPOs) and point-of-service (POS) plans to approximately 6.7 million individuals across the country through group, individual, Medicare, (including the Medicare prescription drug benefit commonly referred to as Part D), Medicaid, TRICARE and Veterans Affairs programs. The Company operates within two segments: Health Plan Services and Government Contracts.