Manager Appeal & Grievance (Hybrid - Troy, MI) - Health Alliance Plan

GENERAL SUMMARY:

To plan, direct, evaluate and coordinate the activities associated with the Monitoring & Oversight department of Customer Services, as it relates to key HAP initiatives and service excellence. To perform auditing and real-time monitoring of complaints, grievances and, appeals for all product lines (HMO, AHL, Medicare Advantage (MA) and Prescription Drug Plan (PDP) to ensure complete, accurate and timely processing, in accordance with regulatory mandates including NCQA, Department of Labor (DOL) and Center for Medicare/Medicaid Services (CMS). To analyze, maintain and report on all grievance and appeal related information to the Department of Financial Services (DIFS), CMS, Member Services Committee of the HAP Board of Directors, CEO and 
COO of HAP and the Vice President of Customer Services. Maintain formal history of grievances and appeals to utilize for process improvements, forecasting and planning for people, resources and technology. To develop and implement an on-going training plan for all resources handling complaints, grievances and appeals and ensure staff is aware of changing regulatory requirements.

PRINCIPLE DUTIES AND RESPONSIBILITIES:

• Provides daily direction, monitoring and oversight for Appeal and Grievance Department, which includes the appropriate coaching and development, planning, staffing and coordination of activities as they pertain to divisional and corporate goals, strategies and objectives.
• Provides daily strategic direction, planning and forecasting for the Appeal and Grievance and Oversight team to ensure departmental, corporate and system initiatives are defined, implemented, tracked, monitored and achieved.
• Determines training, policy, procedure and benefit needs related to timely and accurate processing of all case types.
• Ensures compliance within the individual regulatory mandates for every product line (NCQA, DIFS, DOL, HIPAA and CMS) an operate within HAP defined business processes.
• Supplies necessary internal control oversight information regarding system changes affecting the Appeals & Grievance processing ensuring that proper system testing, system documentation, user training, etc. is performed prior to implementation.
• Develops and reviews department and corporate operational policies and procedures in accordance with DIFS, NCQA, DOL and CMS regulations and within departmental standards. Leads team to ensure workflow is continuous, performance standards are met and staff operates within the regulatory mandates such as CMS, NCQA, DIFS, DOL and HIPAA with respect to the various product lines.
• Partners to collect and submit the corporate grievance and appeal reports for Medicare Part B, C & D that must be electronically sent to CMS for Data Validation.
• Monitors the timely completion of all cases that are submitted through the Medicare Complaint Tracking Module (CTM), DIFS, Pega, and Appeals and Grievances.
• Prepares all appeal and grievance data for regulatory agency reviews (NCQA, CMS, DIFS and Medicare 5 Star). Attends regulatory agency interview meetings during their review of the appeal and grievance data to answer questions and explain monitoring processes to the various interviewers from these agencies.
• Develops, maintains and implements an on-going training plan for the appeals and grievance personnel to provide department-wide or individualized training based on audit results. Develops weekly audit reports to share with management and teams. Provides just-in-time training to staff based on real-time monitoring results.
• Supports achievement of HAP and Department specific KPIs to measure compliance and operational performance. Supports in identifying key areas of process improvement activities to help achieve of HAP’s Medicare 5-Star metric goals as it relates to appeal, grievance and complaints.
• Participates in Medicare Programs workgroups to ensure successful achievement of corporate objectives and regulatory compliance. Participates in Medicare Program conference calls with CMS to ensure changes are understood and communicated effectively to appropriate staff.
• Analyzes complaint, appeal and grievance data to identify impacting trends, perform root cause analyst and recommend customer service and process improvements. Coordinate preparation of annual appeal and grievance report. Presents report to the Member Services Committee of the HAP Board of Directors annually.
• Develops skills and competencies of indirect reports to maximize employee engagement, increase productivity and create an environment of teamwork and commitment; coach and counsel people to exceed performance levels through professionalism, positive relations and timeliness in all customer contacts.