Dir GAU

About the role

Direct the development and administration of unit responsible for the resolution of member and provider grievances and appeals. Oversee the coordination of member and provider complaints, grievances and appeals for all products. Ensure policies, procedures, and operations are consistent with state and federal guidelines and Centers for Medicare and Medicaid Services (CMS) requirements. Ensure programs, plans, and policies align with the company’s philosophy and objectives.

Responsibilities

• Oversee the work of the business unit responsible for the resolution of member and provider grievances and appeals.
• Provide leadership and direction to first line management including performance management oversight and employee development.
• Direct the implementation and administration of the company’s member and provider grievance and appeals programs.
• Oversee the coordination, research, negotiation, and resolution of member and provider complaints, grievances and appeals for all products.
• Ensure timely and accurate achievement of performance measures.
• Ensure the timely submission of regulatory reporting.
• Oversee the completion of program metrics, monitoring improvement and compliance.
• Develop and implement quality improvement strategies based on the identification of the origin of complaints and appeals.
• Monitor and measure process improvement.
• Ensure policies and procedures are current with all state and federal regulations and CMS requirements to ensure organizational compliance.
• Develop and ensure adherence to goals and deadlines.
• Perform other duties as assigned.

Requirements

• Bachelor’s degree in Business Management, Business Administration, or Healthcare Administration or related field, or an equivalent combination of education and experience
• Seven to ten years experience in managed care or health plan operations
• Five to seven years management experience or experience leading a team
• Complaint resolution experience
• Knowledge of regulatory requirements under Medicare/Medicare Managed Care and the Part D programs
• Knowledge of grievance and appeals processes
• Knowledge of health insurance laws and regulations
• Ability to collaborate while dealing with complex situations
• Ability to think creatively and to drive innovation
• Ability to influence up and across the organization
• Ability to motivate, lead and inspire a diverse group to a common goal/solution with multiple stakeholders
• Ability to convert business strategy into action oriented objectives and measurable results
• Ability to develop and manage a budget
• Strong negotiating, influencing, and consensus-building skills
• Ability to mentor, coach and provide guidance to others

Benefits

• Flexible work arrangements that include remote and hybrid opportunities
• Paid time off
• Tuition reimbursement
• Assistance with student-loan repayment
• Health, dental, and vision insurance
• Programs that support mental health and well-being
• Competitive pay, bonuses and investment plans
• Additional paid time to volunteer

Pay

$102,300.00 – $163,700.00

Schedule

• In-office: onsite 5 days per week
• Hybrid: onsite 2–4 days per week
• Remote: onsite 0–1 days per week

Permitted to reside in: Arizona, Connecticut, Florida, Georgia, Louisiana, Massachusetts, North Carolina, Oklahoma, Rhode Island, South Carolina, Texas, Virginia