Supervisor, Appeals & Grievances

<strong>Working at Advantasure is more than a job &mdash; you&rsquo;re part of a team that is becoming the country&rsquo;s leading healthcare solutions provider.<br /></strong><br /><strong>A career at Advantasure means you&rsquo;ll be part of one of the most dynamic, diversified and innovative healthcare companies in the nation. You&rsquo;ll be helping our clients make their members healthier &mdash; and our communities a better place to call home.</strong>

Lansing, MI*


<p class="p1"><strong>At Advantasure, we partner with healthcare clients to simplify their operations and accelerate their business success. Powered by our broad expertise and a comprehensive suite of product and service solutions, we help health plans effectively navigate the complexity of healthcare.</strong></p>

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Competitive Compensation and Benefits Package

Overview: <p>The Appeals and Grievance Supervisor is responsible for managing A&amp;G Analysts and the overall compliant processing of Appeals and Grievance cases.&nbsp; The supervisor is responsible for implementing training, identifying continuous improvement opportunities, and ensuring that completed cases are audit-ready and fully compliant.&nbsp; The Appeals and Grievance Supervisor will ensure that cases are assigned and documented in the highest quality possible and conduct tracking and trending activities to ensure identified issues are communicated to the appropriate business leader.</p>
Responsibilities: <ul> <li>Monitor&rsquo;s inventory and assigns work to analysts on the team</li> <li>Demonstrates excellent working knowledge of Appeals and Grievance regulations and CMS guidance.</li> <li>Demonstrates ability to convey working knowledge of Appeals and Grievances regulations and CMS guidance to A&amp;G Analysts.&nbsp;</li> <li>Follows Grievances and Appeals processes and systems to ensure data quality to support Advantasure&rsquo; s quality, production and financial goals.&nbsp;Performs Appeals and Grievance process oversight activities.</li> <li>Develops and updates Desk Level Procedures and uses these DLPs to conduct training to A&amp;G Analysts.</li> <li>Investigate and thoroughly document findings on grievances and appeals as needed.</li> <li>Produces QA reports to conduct prospective auditing</li> <li>Works with Operations QA team to determine valid processing errors and used that feedback to reeducate A&amp;G Analyst.</li> <li>Conducts post case closing analysts to ensure case meets all CMS Universe requirements</li> <li>Mentors new and existing A&amp;G Analysts and assists with their case processing as needed</li> <li>Ensures all A&amp;G SLAs are met and that A&amp;G cases are processed timely</li> <li>Develops proactive strategies to train A&amp;G analysts on how to properly manage individual inventory</li> <li>Coordinate appropriate reviewer assignment for Appeals and Grievance cases.</li> <li>Responsible to ensure Appeals and Grievances move through each review level to ensure timely completion.</li> <li>Drive operational excellence into all processes and departmental interactions based on CMS and Advantasure requirements.</li> <li>Bring to management&rsquo;s attention any system or process issues determined during the investigation of the appeal or grievance.</li> <li>Coordinate effectively with the Information technology department and vendors on upgrades, fixes, and system changes.&nbsp; In addition, conduct system testing as needed.</li> </ul>
Requirements: <p><strong>EDUCATION OR EQUIVALENT EXPERIENCE:</strong></p> <p>Bachelor&rsquo;s degree in Business Administration, Economics, Health Care, Information Systems, Statistics, or another related field is required. Master&rsquo;s Degree in related field preferred. Relevant combination of education and experience may be considered in lieu of degree. Certification or progress toward certification is highly preferred and encouraged.</p> <p>&nbsp;</p> <p><strong>EXPERIENCE:</strong></p> <p>Two years&rsquo; experience in a supervisory or management role. Experience in healthcare or insurance industry is considered a plus.&nbsp; Experience in leading projects, coordinating efforts that involve other people and demonstrated leadership skills. Five years&rsquo; experience in a grievance and appeals environment including experience with the grievance and appeals regulations per CMS. Experience&nbsp;in medical benefits and health care industry regulations and processes; experience in claims, authorizations, and Medicare Advantage plans. Experience working in or with Medicare Advantage plans, or Independent Review Entities. Experience with CMS regulations regarding Medicare Advantage, and Medicare Advantage plans appeals and grievance processes. Experience in legal research and monitoring of federal and state regulatory laws and legislations preferred.</p> <p>&nbsp;</p> <p><strong>SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:</strong></p> <ul> <li>Knowledge in claims, authorizations, and Medicare Advantage plans.</li> <li>Working knowledge of data languages such as SAS or SQL.</li> <li>Strong analytical, organizational, planning and problem-solving skills.&nbsp;</li> <li>Ability to effectively interface with employees at all levels.&nbsp;Understand and apply statistical inference.&nbsp;</li> <li>Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals.</li> <li>Ability to write reports and correspondence.</li> <li>Ability to speak effectively before groups of customers or employees of organization.</li> <li>Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.</li> <li>Ability to define problems, collect data, establish facts, and draw valid conclusions.</li> <li>Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.</li> <li>Demonstrated track record of generating results and having an impact on organizations.</li> <li>Strong focus and drive to serve the customer.</li> <li>Ability to work in a high paced environment.</li> <li>Ability to consistently exceed deadlines.</li> </ul> <div id="gtx-trans" style="position: absolute; left: -50px; top: 26.7639px;">&nbsp;</div>