Team Lead, Grievance & Appeals

Job Summary:

The Team Lead, Grievance and Appeals oversees the day-to-day performance of grievance and appeals specialists, while ensuring all regulatory, compliance and HIPAA guidelines are met for Medicaid, Medicare and the Massachusetts Market.

Essential Functions:

• Supervise staff for quality review, performance feedback, disciplinary issues and merit/bonus appraisal review
• Meet all monthly, annual and semi-annual reporting deadlines
• Work with Regulatory Compliance Officers to ensure that requests are resolved within time lines and tracked for reporting
• Monitor Medicaid and Medicare processes to ensure that all regulatory requirements are followed
• Work with support departments and compliance officers to ensure policies and procedures are current
• Establish an audit process
• Responsible for evaluating operations and identifying process improvement needs. Identify irregular trends with grievances and appeals; work with other areas as appropriate to identify root causes and appropriate steps for resolution
• Responsible for staffing, ensure that open positions are filled, and evaluate future staffing needs
• Review validation reports to ensure that grievances and appeals are accurate
• Develop and monitor workflows for Grievance and Appeals Department that ensures maximum level of productivity
• Monitor member-facing departments to ensure that grievances and appeals are resolved and reported to the Grievance and Appeals Department
• Conduct audits and provide feedback to all areas that submit grievances and appeals
• Facilitate timely resolution of member and provider issues.
• Ensure that Grievance and Appeals Specialists are available to respond to incoming calls
• Coordinate incoming information and disseminate to staff to ensure accuracy of communication to internal and external customers.
• Create, review, revise and enforce company and departmental policies and procedures
• Act as the contact point for CareSource on operational issues to all regulatory bodies in existing and future lines of business
• Actively interact with IT department for immediate problem resolution and for coordination of data transmissions
• Proactively keep the management team apprised of the team’s performance, projects and issues
• Provide support to the Service Center during high call volume or other support as needed
• Develop, deliver or coordinate the delivery of grievance and appeals training to other areas as needed.
• Perform any other job related instructions, as requested

Education and Experience:

• Associates Degree or equivalent years of relevant work experience required
• Minimum of three (3) years of customer service experience in an HMO or related industry
• Previous supervisory/leadership experience preferred

Competencies, Knowledge and Skills:

• Basic computer skills including Microsoft Word, Excel and PowerPoint
• Basic experience with ACD systems
• Basic experience with Call Management Systems
• Communication skills
• Prior supervisory skills
• Ability to work independently and within a team environment
• Attention to detail
• Familiarity of the healthcare field and knowledge of Medicaid
• Critical listening and thinking skills
• Training/teaching skills
• Strategic management skills
• Negotiation skills/experience
• Proper grammar usage
• Technical writing skills
• Time management skills
• Proper phone etiquette
• Customer service oriented
• Decision making/problem solving skills
• Strong language skills
• Ability to write comprehensive statements using proper grammar and sentence structure

Licensure and Certification:

• None

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time

Compensation Range:

$62,700.00 - $100,400.00

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Salary

Organization Level Competencies

• Fostering a Collaborative Workplace Culture

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.

Brand=CareSource

Originally posted on Himalayas