Director of Appeals & Grievance

Job ID: J116252
Company: Highmark Inc
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Jan 26, 2018

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Description

JOB SUMMARY

This job serves as the single accountable leader for end-to-end processing of Medicare appeals, grievances, and Complaint Tracking Modules (CTMs) for the Organization. The incumbent manages department initiatives to develop a member-centric appeals, grievance, and CTM function, reduce compliance risk, and improve applicable Star ratings measures. Works closely with key partners in the Organization to facilitate integration with the call center, clinical pharmacy, claims payment, and the broader health plan organization.

ESSENTIAL RESPONSIBILITIES

  • Perform management responsibilities including, but not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity.  Plan, organize, staff, direct and control the day-to-day operations of the department; develop and implement policies and programs as necessary; may have budgetary responsibility and authority.
  • Set and manage to the strategic vision and objectives for Medicare appeals, grievances, and CTMs at Highmark based on regulatory insights and operational needs.  Ensure that department activities and priorities align with the overall plan’s broader vision and strategic objectives.
  • Coordinate with internal partners to ensure appropriate coordination and oversight of clinical decision making and processing timeframes.  Coordinate with Government Compliance to implement compliance requirements.
  • Chair governance committee, which is responsible for facilitating collaboration between the department and key stakeholders, such as Compliance, Government Quality, Clinical Services, and the MDs
  • Own the end-to-end appeals, grievances, and CTM process, including all intake, administrative, and clinical components in accordance with CMS requirements, including applicable appeals Star ratings measures
  • Other duties as assigned or requested.

EDUCATION

Required

  • Bachelor's Degree

Substitutions

  • 6 years of Healthcare Operational Appeals experience at a director/manager level in lieu of degree

Preferred

  • None

EXPERIENCE

  • 7 - 10 years in the Healthcare Industry

To include

  • 5 - 7 years in Management
  • 3 - 5 years in Appeals

Preferred

  • 3 - 5 years in Medicare
  • 1 - 3 years in Lean/Six Sigma

LICENSES AND CERTIFICATIONS

Required

  • None

Preferred

  • None

SKILLS

  • Communication Skills
  • Relationship-builder with Unsurpassed Interpersonal Skills
  • Medicare
  • Operations Management
  • Problem-Solving
  • Analytical Skills
  • Capacity Planning
  • Government Programs
  • Process Improvement
  • Talent Management

Language (Other than English)

None 

Travel Required

0%  - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-Based

Teaches / trains others regularly

Frequently

Travel regularly from the office to various work sites or from site-to-site

Rarely

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required 

Yes

Lifting: up to 10 pounds

Frequently

Lifting: 10 to 25 pounds

Occasionally

Lifting: 25 to 50 pounds

Rarely

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org

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