Director, Grievance & Appeals Regulatory Complaints

Summary of Position

Direct oversight of the Regulatory Complaint functions, ensuring compliance with all regulatory, state and federal guidelines
for all product lines. Research and implement methods to improve the effectiveness and efficiency of operations in the unit. Responsible for completion and monitoring of all internal and regulatory related reporting. Identify regulatory complaint trends, performing root cause analysis and implementing corrective actions as required. Work with internal department leadership to construct corrective actions in response to regulatory complaints, ensuring
resolutions best support our internal processes and resources and are implemented in a timely fashion.

Responsibilities:

Departmental Operations:
• Direct oversight of Regulatory Complaints processing.
• Ensure that department goals are being met efficiently and effectively.
• Monitor daily reports to ensure that all timeframes are met to maximize member and provider satisfaction.
• Responsible for ensuring timely and accurate responses to all regulatory complaints.
• Ensure the accuracy and resolution of all cases includes handling of the underlying issue reported on the complaint.
• Communicate with CMS/State regional office liaison on a regular basis.

Research and Problem Solving:
• Research and resolve all issues presented to the Plan by regulatory agencies.
• Responsible for identification and root cause analysis of complaints.
• Determine action plans and work with affected area to implement corrective action.
• Understand, assess, and provide resolution of the overall member and provider impact of identified issues.
• Continuously measure effectiveness of corrective action.

Other Management Functions:
• Participate in meetings and present to committees to represent the Grievance and Appeal Department.
• Ensure that all quarterly, mid-year and annual performance reviews are conducted for management staff.
• Provide guidance, training, and motivation to staff.
• Create and manage relationships with all applicable regulatory oversight bodies.

Audits and Reporting:
• Responsible for submission of all internal and regulatory related reporting.
• Responsible for accurate preparation and execution of all internal and regulatory audits, including submission of
universe, review of audit findings, and the development and implementation of any required corrective actions.
• Develop required reporting for various committees, providing analysis of receipts and outcomes.

Policy and Procedure:
• Conduct training with staff on new and/or updated policies and procedures.
• Provide interpretation and guidance to staff.
• Regular attendance and demonstrated flexibility are essential functions of the job.
• Perform other duties as assigned or required.