GENERAL SUMMARY: 

The Lead Appeal & Grievance Support is responsible for daily oversight of inventory management for the Appeal & Grievance (A&G) department.

Responsible for preparing daily inventory reports to provide management with updates as needed and speak to team performance.

The Lead Appeal & Grievance Support will also be responsible for assisting with Monitoring and Oversight case reviews by reviewing all grievance and appeals cases before staff mails decision letters to members. The Lead Appeal & Grievance Support may be responsible for case investigations and back-up as needed.

The Lead Appeal & Grievance Support will assist A&G staff with determining appropriate outcomes for grievances and appeals by working with internal support departments and in accordance to regulatory guidelines. The Lead Appeal & Grievance Support will also assist with the ongoing development and maintenance of Desk Level Procedures, departmental policies and procedures, and capture data to identify trends in order to proactively address member concerns.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

• Act as departmental subject matter expert (SME) in order to provide guidance, direction and assistance to the A&G department Research and answer unknown benefit or procedural questions.

• Assist A&G leadership in workforce management activities, including scheduling, time off review, queue management, forecasting and providing administrative support.

• Assist with various corporate process planning, departmental projects and other outreach activities.

• Provide training support to A&G team to identify procedural information necessary for the ongoing development of the A&G team.

• Assist department leadership with external vendor management projects within A&G.

• Liaison for all system operations in order to partner with internal and external customers to resolve any issues, provide information for system updates and implementations, submit PCR, and communication with IS Helpdesk.

• Lead projects that support A&G business model activities. Ensure that all support and services delivered to internal and external customers are completed with high quality and in a timely effective manner.

• Serve as first line contact for A&G Analyst for day to day operational issues.

• Function as a liaison with plan-wide stakeholders to ensure service level agreements and workflows with internal support departments such as Membership & Billing, Health Care Management, Coordinated Behavioral Health Management, Pharmacy Care Management, Claims, Provider Services, and Sales.

• Partner with Monitoring & Oversight and Compliance to conduct and coordinate compliance training when needed and ensure that compliance information is disseminated to A&G staff, as appropriate.

• Co-facilitate in team huddle meetings.

• Weekend coverage as required for overturning authorizations to ensure timely review of appeal.

• Conduct onboarding for new and temporary team members.

• Perform other related duties as assigned.