Job ID: J117640
Company: Highmark Inc
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Feb 15, 2018
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.
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.
Minimum Education and Experience
Preferred Education and Experience
Knowledge, Skills and Abilities
SCOPE OF RESPONSIBILITY
Does this role supervise/manage other employees? Yes
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)
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