Manager - Medicare Grievance & Appeals (prior mgmt/operations and Medicare experience)
Blue Cross Blue Shield of Arizona is a local, independent Blue Cross Blue Shield Association and a not-for-profit health insurance company headquartered in Phoenix. Founded in 1939, the company has more than 1,800 dedicated employees throughout its Phoenix, Tucson, Chandler and Flagstaff offices. Providing health insurance products, services and networks to more than 1 million Arizonans, Blue Cross Blue Shield of Arizona offers various health plans for individuals, families, and small and large businesses. Blue Cross Blue Shield of Arizona also offers Medicare supplement plans to individuals over age 65.
Blue Cross Blue Shield of Arizona helps to fulfill its mission of improving the quality of life of Arizonans by delivering a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.
- Act as a talent and culture ambassador for the Medicare Grievance & Appeals team in support of hiring, training, and retaining the best talent and in connecting employees emotionally to our Vision and Mission. Employee Engagement is a critical accountability in this role as our customers will never be happier or more satisfied than our employees are engaged.
- Serve as a Subject Matter Expert and coordinates end-to-end tactical execution across the Medicare Grievance & Appeals ecosystem for Medicare Advantage, Medicare Part D, and Out Of Network Provider Appeals functions along with support of our delegated entities/value based care arrangements (related to G&A) to ensure operational performance and regulatory standards are met or exceeded. Collaborate and coordinate closely with the Chief Medical Officer, Medical Directors, Customer Care, Compliance and other teams/entities as needed.
- Develop and implement strategy and tactics to resolve member grievances and clinical appeals timely and accurately. Lead Medicare G&A team as people leader, maintain team strategies, goals and objectives, and performance monitoring and management, and ensure engaged, timely and accurate customer service with internal and external constituents.
Required Work Experience
- 3 years leading people and operations to success; strong preference for demonstrated Medicare and Medicaid operations experience
- High School Diploma or GED
Preferred Work Experience
- 5 years of experience in management in the healthcare field
- BA or BS degree in business administration, healthcare, nursing, or related field
ESSENTIAL job functions AND RESPONSIBILITIES
- Manage and advise the organization on an effective grievance and appeals system consistent with policies and procedures, department goals and regulatory requirements
- Assure that regulatory timelines are met through departmental processes and procedures
- Knowledgeable of CMS rules and regulations relating to the Grievance and Appeals processes
- Maintain and updates all related policies and procedures, and desktop procedures
- Actively participate in CMS audits and related activities. Responsible for resolving any identified findings through corrective action, in collaboration with the Compliance team
- Actively monitors grievance and appeal activity to readily identify any trends, and correct non-compliance or processing errors. Monitors processing timeliness, verbal and written communications and case volume
- Coordinate investigations and resolution of complex appeal and grievance issues
- Recruit, train and evaluate department staff.
- Serve on the Compliance Committee and other committees as assigned
- Maximize the use of available data to manage, summarize and report on grievance and appeals trends, productivity and compliance.
- Work closely with Grievance and Appeals representatives to develop and prepare case files for Medical Director or IRE review and in support of ALJ Hearings
- Review and overturn appeal cases based on established criteria, Medicare coverage guidelines, National Coverage or Local Coverage Determinations, and company policy
- The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements including on-call support.
- Identify, research, process, resolve and respond to customer inquiries and correspondence via telephone, written communication and/or in person.
Required Job Skills
- Working knowledge of Medicare Advantage and Medicare Part D appeals and grievances regulations and guidance
- Knowledge of complaint resolution, Medicare benefits, and cross-functional processes
- Knowledge of managed care systems and medical administration
Required Professional Competencies
- Familiar with claims and/or utilization management processes
- Independent decision-making and sound judgment to prioritize work and ensure appropriateness and timeliness of each request
- Ability to interpret events surrounding member’s experiences to appropriately address grievances
- Management experience
- Strategic and problem-solving skills
- Leadership skills
- Strong interpersonal skills
- Ability to assess high risk issues and escalate as appropriate
- Strong verbal and written communication skills
- Conflict resolution and coaching techniques
Required Leadership Experience and Competencies
- Make use of employees' skills and abilities to deliver business objectives
- Use available information to focus the team's activities and identify priorities
- Develop and execute business plans to focus the team's activities and identify priorities
- Resource management skills
- Leadership skills
- Ability to empower employees and encourage innovation
Preferred Job Skills
- Work independently under regular supervision, leads and follows structured work routines
Preferred Professional Competencies
Preferred Leadership Experience and Competencies
BCBSAZ does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group.
Thank you for your interest in Blue Cross Blue Shield of Arizona. For more information on our company, see azblue.com. If interested in this position, please apply.
Imagine doing life-changing work and helping more than one million Arizonans live healthier and longer lives. That’s the kind of satisfaction you’ll find when you work here. Our exceptional teams in Phoenix, Tucson, Chandler, and Flagstaff have been transforming healthcare for more than 80 years. Explore what's possible with a career at Blue Cross® BlueShield® of Arizona