Central California Alliance for Health is hiring a Grievance Supervisor

About the Role

Role details below.

Responsibilities

• Supervises Grievance Unit functions, acts as a subject matter expert, and provides guidance on Grievance unit activities
• Ensures compliance with regulations and requirements related to the resolution of grievance cases and participates in the fulfillment of regulatory requirements
• Supervises, mentors and trains assigned staff
• Participates in departmental and cross-departmental projects, programs, workgroups, committees, and operational improvement activities

Requirements

• Knowledge of the principles and practices of healthcare coverage and benefit structures, the principles of coordination of benefits, and medical billing
• Knowledge of Medi-Cal program and related regulations
• Knowledge of Title 22 and Title 28 utilization management and grievance regulations
• Knowledge of principles and practices of customer service
• Knowledge of principles and practices of managed health care
• Ability to act as technical resource and explain regulations, processes, and programs related to area of responsibility
• Ability to learn, interpret, and apply Medicare D-SNP regulations and act as a subject matter expert on D-SNP within the Grievance Unit
• Ability to supervise, train and evaluate the work of staff
• Ability to motivate staff and promote an atmosphere of teamwork and cooperation
• Ability to plan, organize and prioritize tasks and work schedules, manage projects, and adhere to timelines
• Ability to identify issues, conduct research, gather and analyze information, reach logical and sound conclusions, and make recommendations for action
• Bachelor’s degree in Social Sciences, Health, Business or a related field
• Four years of experience in a managed health care environment performing work related to billing, claims payment, coding or a closely related function, including some lead or supervisory experience

Nice to Have

• A Master’s degree may substitute for two years of the required experience
• An equivalent combination of education and experience may be qualifying

Additional Information

• Grievance work involves complex coordination, investigation, and specific resolution within regulatory timeframes
• Areas of Grievance work include Appeals, Member Grievances (Complaints), Expedited Appeals/Grievances, State Fair Hearings, Inquiries, and Complex Member Billing Issues or Member Reimbursements
• Interdepartmental Collaboration: Grievance collaborates with each department within the Alliance; cases are routed to Subject Matter Experts (SMEs) in other departments for investigation and resolution
• SMEs are required to clearly document within the Grievance System: the steps of their investigation, the determination of each case, and whether the Alliance's in