Company Statement
Connecticare is a leading health plan in the state of Connecticut and a subsidiary of EmblemHealth, a health and wellness company that provides insurance plans, primary and specialty care, and wellness solutions. WellSpark is a digital wellness company and national subsidiary of EmblemHealth that offers a full suite of products and solutions to reward people for healthy behaviors.
Supervisor, Grievance & Appeals
🔍 New York, New York
Summary:
Responsible for overseeing the day-to-day operations of the Grievance and Appeal Specialists, ensuring adherence to department performance standards and operational efficiency. Continuously improve the effectiveness and efficiency of operations in the assigned unit, utilize working knowledge of all G&A areas to ensure that the department is fully compliant with all government regulations. Monitor staff to ensure adherence to all department and company policies. Work with other departments to maximize cooperative relationships; act as an interface with others for excellent customer service and process improvement.
Responsibilities:
• Manage the day-to-day operations of the staff including new hires.
• Ensure the appropriate staff responds to all member/provider inquiries within the stipulated time frames, thereby ensuring member/provider satisfaction and compliance.
• Have accountability for all performance issues and take appropriate action as warranted. Maintain coverage for expedited appeal files on weekends and holidays to ensure EmblemHealth remains complaint as applicable.
• Responsible for identification and root cause analysis of appeal issues, working with applicable business areas to resolve issues.
• Review daily/weekly pend reports to ensure that proper research is being performed and timeframes are met.
• Review quality audits on staff files to effectively evaluate performance and ensure compliance.
• Work with staff as needed to improve performance: monitor attendance and punctuality; complete performance reviews; conduct weekly staff meetings to encourage open communication and build team morale.
• Manage delegate relationships (Beacon, HCP, CMO, EviCore, etc.); collaborate with them to develop workflows, resolve appeal and grievance issues and implement quality improvements.
• Create and implement policies and procedures to ensure that department goals are met using the most efficient and cost-effective measures. Participate in creating and implementing continuous process and quality improvement initiatives while fostering a team environment to maintain a high performing unit.
• Conduct root cause analysis: implement process improvements based on findings. Prepare for internal/external audits.
• Participate in the recruitment of qualified candidates for all open positions and arrange and monitor the training process for new staff members. Monitor staff performance and address any problems during the probationary period.
• Regular attendance is an essential function of the job; perform other duties as assigned or required.
Qualifications:
• Bachelor’s Degree
• 4 – 6+ years of relevant, professional work experience required
• 1 – 2+ years of managed care experience required
• Staff/process management experience preferred
• Additional experience/specialized training may be considered in lieu of educational requirement required
• Knowledge of EmblemHealth’s programs, and of the department’s web-based programs preferred
• In-depth knowledge of grievance and appeal processes, federal /state regulations, and contractual/processing guidelines required
• Proficient in MS Office (Word, Excel, PowerPoint, Outlook, Teams, etc.) required
• Supervisory skills sufficient to direct, motivate, and discipline staff required
• Analytical and technical ability to review and analyze procedures and workflow and to make recommendations for
streamlining the grievance and appeals process within the functional units of the department required
• Strong communication skills (verbal, written, presentation, interpersonal) with all types/levels of audience required
• Ability to organize, prioritize, and effectively manage multiple tasks/projects with competing priorities/deadlines required
• Proven ability to manage a heavy workload in a dynamic, fast paced environment required
• Ability to problem solve, make appropriate decisions, and seek assistance when necessary required
Security Disclosure
If you are offered a job from one of the EmblemHealth family of companies that includes ConnectiCare, AdvantageCare Physicians, and WellSpark, the offer confirmation email will come from “HRTalentAcquisition” with the subject line: “Offer of Employment for (job title)” – Please respond online”.
We never ask you to join a Google Hangout, request you to purchase your own equipment or pay to apply. We do not send email from a third-party email service such as Yahoo or Gmail.
Pay Disclosure
A good faith estimate of the compensation range for individuals hired to work for the EmblemHealth Family of Companies is provided. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate’s work experience, education/training, internal peer equity, and market and business considerations. The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. It is not typical for an individual to be hired at or near the top of the range, as compensation decisions depend on each case’s facts and circumstances. Union roles covered by a collective bargaining agreement will compensate in accordance with the union contract.
EEOC Statement
We are committed to leveraging the diverse backgrounds, perspectives, and experiences of our workforce to create opportunities for our people and our business. We are an equal opportunity/affirmative action employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex/gender, sexual orientation, gender identity or expression, pregnancy or related condition, marital status, national origin, disability, protected veteran status or any other characteristic protected by law.