Spv Appeals & Compliance Admin

Job ID: J117640
Company: Highmark Inc
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Feb 15, 2018

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Description

GENERAL OVERVIEW: 

This position is responsible for the direct oversight and administration of assigned commercial member appeals and grievances processes.  It ensures that resolution is in accordance with all applicable state and federal laws, mandates, guidelines and timeframes.  It conducts all auditing activities for assigned areas, trends appeals and grievances data, and facilitates meetings to review data for process/product improvements.  This position is also responsible for the direct oversight and administration of assigned legislative, executive, regulatory and high profile inquiries, with responses to executive management and regulatory agencies.     

ESSENTIAL RESPONSIBILITIES:

1. Communicate effectively in both verbal and written form, understanding that the audience regularly includes senior level management and regulatory agencies, including Attorneys General Offices, State Insurance Departments and other Government Offices.   

2. Effectively supervise all assigned personnel.  Ensure continuous improvement. 

3. Ensure that members are entitled to fair and equitable appeals and grievances process which meet all state, federal, and client contractual requirements, and that all appeals and grievances data is maintained in a database, which can report statistical data and audited compliance data to appropriate parties.  Maintain compliance with the vast variety of appeals processes that exist for the corporation’s extensive ASO client base.      

4. Accountable for financial penalties and sanctions related to any non-compliant findings cited during the regulatory audit process, ensuring that state licensure is maintained, and ensure that all appeals and grievances activities meet or exceed all applicable state and federal laws.

5. Accountable for maintaining accreditation/licensure in designated states, to ensure the corporation’s ability to perform utilization management functions in those states.   

6. Act as a consultant to ensure that member appeals and grievances processes meet all regulatory requirements.  Oversee appeals and grievances processes to ensure compliance with all regulatory and accreditation requirements.  Develop new policies, procedures and work-flows, revise existing policies, procedures and work-flows in order to ensure the efficient and effective operation of the appeals and grievances processes.   

7. Act as corporate representative at mediation hearings, settlement hearings and court trials, and also provide depositions. 

8. Other duties as assigned or requested.

QUALIFICATIONS:

Minimum Education and Experience

  • High School Diploma or GED
  • 2 years of experience in a customer service/claims environment
  • 2 year experience successfully leading or supervising others in a management role

Preferred Education and Experience

  • Bachelor’s degree in Business Administration or similar field

Knowledge, Skills and Abilities 

  • Knowledge of multiple Highmark processing systems and workflows
  • Ability to interpret and understand complex government regulations
  • Knowledge of all Highmark products
  • Ability to handle multiple priorities and identify, analyze and solve problems independently
  • Strong organizational and analytical skills
  • Comprehensive knowledge of state and federal regulations, laws and coverage issues
  • Thorough understanding of operational processes

SCOPE OF RESPONSIBILITY 

Does this role supervise/manage other employees? Yes 

WORK ENVIRONMENT

Is Travel Required? Yes

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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