Grievance & Appeals Team Lead

<p>With more than 7,000 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.</p>

Detroit, MI

Blue Cross Blue Shield of Michigan

When you think of <a href="" target="_blank" rel="noopener noreferrer">Blue Cross Blue Shield of Michigan</a> for health insurance, you can know you&rsquo;re getting much more. We're a company founded on a tradition of affordable, quality health care for everyone, improving the present and investing in the future.<br /><br />We offer:<br />Plans for employers and individuals that meet today&rsquo;s needs, budgets and lifestyle<br />The largest network of doctors and hospitals in the state<br />Lower health care costs Higher quality health care<br />Award-winning diversity practices<br />Grants and programs that promote better health throughout Michigan<br /><strong><br />Mission:&nbsp;</strong>We commit to being our members&rsquo; trusted partner by providing affordable, innovative products that improve their care and health.<br /><br /><a href="" target="_blank" rel="noopener noreferrer"><strong>Click here</strong></a> to learn more about our commitment to our Social Mission, view company updates and reviews, and view our awards &amp; accolades.<br /><br />Learn more about your options as an external candidate. <a href="" target="_blank" rel="noopener noreferrer">Click here</a> to view open positions.

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Competitive Total Compensation Package

Overview: Lead day-to-day operations and work assignments, using discretion and independent judgment. 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: <ul> <li> <div><span style="font-size: small;">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.</span></div> </li> <li> <div><span style="font-size: small;">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.</span></div> </li> <li> <div><span style="font-size: small;">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.</span></div> </li> <li> <div><span style="font-size: small;">Monitors work assignments for adherence to timeliness standards; plans work activities a</span><span style="font-size: small;">nd assignments for the most cost effective and efficient resolutions.</span></div> </li> <li> <div><span style="font-size: small;">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.</span></div> </li> <li> <div><span style="font-size: small;">Conducts on-the-job training of new team members.</span></div> </li> <li> <div><span style="font-size: small;">Interface with internal and external stakeholders to develop and maintain effective relationships to resolve issues, collaborate, create alignment, implement and improve processes.</span></div> </li> <li> <div><span style="font-size: small;">Maintain a thorough knowledge of department/regulatory/accreditation policies, procedures, guidelines and timeframes as well as policies, procedures, and benefits.</span></div> </li> <li> <div><span style="font-size: small;">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.</span></div> </li> <li> <div><span style="font-size: small;">Other duties as assigned.</span></div> </li> </ul>
Requirements: <strong>Qualifications</strong><br /> <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>