Grievance & Appeals Team Lead

<p><strong>With more than 8,000 employees, we are the largest health insurance company in Michigan. We offer an exciting work environment with a diverse group of employees. Our goal is to make health insurance easier for our members. We want to transform the industry and become a resource that people can trust. Interested in joining us?</strong></p>

Detroit, MI

Blue Cross Blue Shield of MI

Our Mission: We commit to being our members&rsquo; trusted partner by providing affordable, innovative products that improve their care and health. Our Customer Commitment: We aspire to be clear and simple, to help you make the right choices, to offer valuable coverage, and help you get quality health care for you and those you love. Our Commitment to our Social Mission: Increasing access to affordable health care Enhancing the quality of care patients receive Improving the health of Michigan&rsquo;s citizens and communities. <br /> <p><br />Our employees are eligible for several great perks:</p> <ul> <li>Comprehensive medical, dental and vision insurance</li> <li>401(k) with company match</li> <li>Annual bonuses</li> <li>Tuition assistance</li> <li>Paid parking</li> </ul>

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Team Lead

Competitive Total Compensation Package

Overview: Lead day-to-day operations and work assignments, using discretion and independent judgment.&nbsp; Supervise a team which responds to grievances, appeals, and complaints to ensure the resolutions are consistent with department, regulatory, and accreditation guidelines and are efficient and cost effective, aligning with department and corporate standards and objectives. Provide guidance to staff.
Responsibilities: May lead a team in the analysis, research, and resolution of critical inquiries within the mandated 72-hour timeframe, providing leadership and guidance in working with medical directors and OGC, etc; high level referrals directed to the President and CEO, Board Members, Executive Staff, Media Relations, Better Business, Bureau, Attorney General, Congressional Legislative Offices, etc; provider appeals; and member appeals, grievances, and complaints in accordance within established regulatory and accreditation guidelines. Effectively administer the quality program to ensure accuracy of information communicated to stakeholders and in alignment with state and federal regulations and accreditation guidelines, providing leadership and guidance to the team for the accurate and effective application of regulations. Guide and promote quality and comprehensive appeals and grievances responses that support the decision, comply with regulatory and accreditation guidelines, and reference specific and applicable language from the plan documents, certificates, riders, and summary plan descriptions, or the internal rules guidelines and protocols, as appropriate and the applicable benefit or clinical rationale for the decision. Monitors work assignments for adherence to timeliness standards; plans work activities and assignments for the most cost effective and efficient resolutions. Coach and develop staff to capitalize on strengths, identify areas in need of improvement, and initiate corrective action plans. Recognize and reward staff for achievements and accomplishments. Conducts on-the-job training of new team members. Interface with internal and external stakeholders to develop and maintain effective relationships to resolve issues, collaborate, create alignment, implement and improve processes. Maintain a thorough knowledge of department/regulatory/accreditation policies, procedures, guidelines and timeframes as well as policies, procedures, and benefits. Identify business problems and servicing issues and direct to appropriate area for action.&nbsp; Collaborate with and works with other business areas to resolve servicing issues.
Requirements: <ul> <li>Associate's Degree in English, Communications or related field required. Bachelor's Degree preferred.</li> <li>Five (5) years customer service experience required.</li> <li>Two (2) years experience in a leadership role preferred.</li> <li>Proven leadership experience and/or demonstrated leadership skills and abilities</li> <li>Advanced verbal and written communication skills.</li> <li>Strong PC applications and systems skills (i.e. Microsoft Excel, Word, and Outlook).</li> <li>High regard for protecting confidentiality of corporate information.</li> <li>Ability to organize and prioritize tasks for timely resolution.</li> <li>Ability to apply policies and procedures to arrive at accurate conclusions.</li> <li>Ability to analyze, interpret, apply reason and logic, conduct research and structure a clear and thorough response.</li> <li>Ability to quickly learn and navigate diverse products and information systems.</li> <li>Other related skills and/or abilities may be required to perform this job.</li> </ul> <p>&nbsp;</p> <p><em>All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.</em></p>