Manager Appeal & Grievance (Hybrid - Troy, MI) - Health Alliance Plan
EDUCATION/EXPERIENCE REQUIRED:
- Bachelor’s degree in Health Care, Business or related field required. Master’s Degree preferred.
- Minimum of four (4) years combined customer service and professional experience in health care, call center, business and/or insurance environment or capacity required.
- Minimum of four (4) years of experience with Appeals and Grievances and demonstrated knowledge of HMO and PPO products and CMS regulations and
guidelines for Medicare products required. - Minimum of two (2) years of project coordination or project management and data analysis, validation and reporting required.
- Minimum of one (1) year of CMS Plan or Data Validation Audit experience; NCQA site visit experience preferred.
CERTIFICATIONS/LICENSURES REQUIRED:
- Certified in Health Care Compliance preferred.
SKILLS AND ABILITIES: - Proven managerial skills which include ability to lead teams effectively through a coaching methodology.
- Strong organizational and communication skills, both verbal and written and the ability to express ideas logically, cogently and persuasively.
- Ability to develop and implement recommendations and strategies, make independent judgments and effectively manage multiple responsibilities within
multiple distinct operations. - Excellent analytical and decision-making skills.
- Ability to comprehend and suggest modification to technical computerized systems or other applications as they relate to call center operations.
- Skills to learn in detail the HAP policies, procedures and benefits.
- Skills to develop a good understanding of the health care system and the HAP provider network.
- Thorough understanding of the HMO and Medicare Managed Care delivery systems.
- Extensive knowledge of State, DOL, NCQA and CMS guidelines as related to grievances/appeals and Medicare program regulations.
- Strong human relations skills.
- Technical understanding of database oriented systems.
- Proficient with Word, Excel and/or Access.
- Basic understanding of accounting principles.
Additional Details
This posting represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and functions. It should be understood, therefore, that incumbents may be asked to perform job-related duties beyond those explicitly described above.
Overview
Henry Ford Health partners with millions of people on their health journey, across Michigan and around the world. We offer a full continuum of services – from primary and preventative care to complex and specialty care, health insurance, a full suite of home health offerings, virtual care, pharmacy, eye care and other health care retail. With former Ascension southeast Michigan and Flint region locations now part of our team, Henry Ford’s care is available in 13 hospitals and hundreds of ambulatory care locations. Based in Detroit, Henry Ford is one of the nation’s most respected academic medical centers and is leading the Future of Health: Detroit, a $3 billion investment anchored by a reimagined Henry Ford academic healthcare campus. Learn more at henryford.com/careers.
Benefits
The health and overall well-being of our team members is our priority. That’s why we offer support in the various components of our team’s well-being: physical, emotional, social, financial and spiritual. Our Total Rewards program includes competitive health plan options, with three consumer-driven health plans (CDHPs), a PPO plan and an HMO plan. Our team members enjoy a number of additional benefits, ranging from dental and eye care coverage to tuition assistance, family forming benefits, discounts to dozens of businesses and more. Employees classified as contingent status are not eligible for benefits.
Equal Employment Opportunity/Affirmative Action Employer
Equal Employment Opportunity / Affirmative Action Employer Henry Ford Health is
committed to the hiring, advancement and fair treatment of all individuals without regard to
race, color, creed, religion, age, sex, national origin, disability, veteran status, size, height,
weight, marital status, family status, gender identity, sexual orientation, and genetic information,
or any other protected status in accordance with applicable federal and state laws.