Director, Appeals & Grievances

Position Summary:

Reporting to the VP of Member Experience, the role of the Director, Appeals & Grievances is critical to the success of Alignment Healthcare in realizing its goals and objectives. This individual will play a key role as part of the Member Experience leadership team in delivering and collaborating on all aspects of Appeals and Grievances.

The Director, Appeals & Grievances is responsible for the day-to-day operations of the A&G team, including but not limited to enterprise oversight of appeals & grievance intake, investigation, resolution, tracking and trending of data, and monthly reporting of key indicator reports. The Director will also be responsible for ensuring compliance with CMS requirements.

General Duties/Responsibilities (May include but are not limited to):

• Develops business strategies, manages service, regulatory and financial performance of Appeals and Grievance Programs.
• Provides executive oversight and leadership to Managers, Leads responsible for creating and driving implementation of operating plans, which are required to support immediate and long-term business strategies.
• Ensure KPIs and goals are in place, which are reflective of and measure our strategic, competitive, and regulatory position with ongoing measurement, reporting, and root cause analysis.
• Lead end-to-end process improvements and implement process initiatives throughout the organization designed to create efficiencies and allow us to scale for growth.
• Responsible for the interpretation and translation of regulatory and accreditation requirements into operational procedures that support Alignment compliance with various state and federal laws and accreditation standards.
• Provide thought leadership to the Member Experience Leadership Team, Clinical, and other cross-functional leaders throughout Alignment Healthcare on operational issues.
• Provide effective leadership in attracting and retaining top talent to drive business results.
• Defines, and monitors performance and productivity standards specific to those systems that must be in place to serve Alignments’ enrolled population.
• Accountable for the training, and overall performance of the A&G staff to ensure that all qualitative and quantitative goals and objectives are met within the department.
• Ensure that all grievances/appeals are processed in adherence to the Centers for Medicare and Medicaid (CMS) guidelines and plan policy.
• Accountable for maintaining accurate and timely documentation, including complete files of all grievances/appeals. Prepare monthly and quarterly reports as requested.
• Identify training opportunities and potential system and process improvements relating to grievance/appeal data.
• Defines and implements business requirements for system applications to support appeals and grievances based on business need or change in regulatory requirements.
• Participate in periodic review and update of grievance/appeal policies and procedures to reflect appropriate legal and CMS requirements as well as participate in periodic CMS Audit preparations and regulator meetings/interviews.
• Responsible for the weekly, monthly, and quarterly reports necessary to ensure timeliness and accuracy and integrity of case data.
• Other duties as assigned.

Supervisory Responsibilities:

Directly oversees the Appeals & Grievance Unit within the Member Experience Department. Carries out supervisory responsibilities in accordance with organization policies, CMS rules, and applicable laws. Responsibilities include training of employees; planning, assigning, and managing work; assisting in the rewarding and disciplining of assigned employees; addressing complaints and resolving problems as they pertain to the department.

Minimum Requirements:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed below are representative of the knowledge, skill, and/or ability required.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1.       Minimum Experience:

a.    5+ years healthcare grievance & appeals experience in a managed care organization

b.    5+ years of management/leadership experience in a healthcare company

2.       Education/Licensure:

a.    Bachelor’s degree in healthcare, business, or related field

b.    Master’s degree preferred

3.       Other:

a.    Self-starter with outstanding critical thinking, leadership, and relationship building skills

b.    Strong analytical, problem solving and interpersonal skills

c.    Knowledge of Medicare Managed Care Plans required.

d.    Demonstrated knowledge of CMS Reporting (ODAG, Stars Measures, etc.,)

e.    Previous Supervisory experience required.

f.     Bi-lingual (English/Spanish) preferred.

g.    Strong knowledge of State and Federal regulatory statutes, including Medicaid and Medicare Parts C and D

Essential Physical Functions:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1.       While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or hear.

2.       The employee is frequently required to walk; stand; reach with hands and arms.

3.       The employee is occasionally required to climb or balance and stoop, kneel, crouch, or crawl.

4.       The employee must occasionally lift and/or move up to 20 pounds.