Job Summary:

The Director, Grievance and Appeals is responsible for oversight of appeals and grievance processes.  Directing and ensuring the efficient operational management of appeals and grievance department/ function with emphasis on execution, outcomes, continual improvement and performance enhancement.

Essential Functions:

• Responsible for oversight of appeals and grievance processes.  Directs and ensures the efficient operational management of appeals and grievance department/ function with emphasis on execution, outcomes, continual improvement and performance enhancement
• Designs and implements processes, policies, trainings and procedures to ensure compliance with new and existing regulations
• Addresses areas of below-standard performance and implements mechanisms to bring performance up to standard
• Tracks and trends preventable appeals and grievances and presents findings to Operations leadership
• Minimizes legal and financial risk by taking appropriate measures to protect the interest of members and providers
• Identifies need for in-house legal involvement on sensitive cases, and coordinates with plan attorneys on litigated cases, helping to oversee case preparation and research
• Provides fiscal management and support including developing operation budgets and completing forecasts and variance reporting
• Ensures appropriate systems and technology are in place to meet compliance, quality and operational efficiency measures for the department/ function
• Analyze data regularly to identify and implement process improvements
• Coordinates grievance/appeal committee meeting with appropriate parties
• Establishes and maintains cohesive relationships with internal partners
• Perform any other job duties as requested

Education and Experience:

• Bachelor of Science/Arts (BA/BS) or equivalent years of work experience is required
• Master’s degree is preferred
• Minimum of five (5) years of management experience is required
• Managed care experience is required
• Direct leadership experience in a Healthcare operational G&A environment is required
• Senior management experience is preferred

Competencies, Knowledge and Skills:

• Customer service skills with the ability to interact professionally and effectively with members, providers, internal business areas and colleagues
• Strong analytical skills with the ability to create reports and interpret operational, utilization and financial data
• Proven problem-solving skills with the ability to look for root causes and develop implementable, workable solutions
• Computer proficiency with knowledge and experience in a Windows environment
• Maintain regulatory knowledge for compliance
• Customer service orientation
• Strong written and verbal communication skills
• Ability to work in a fast paced environment
• Decision making and problem solving skills

Licensure and Certification:

• None

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time

Compensation Range:

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Fostering a Collaborative Workplace Culture

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.