Team Leader Grievance and Appeals

Looking for a way to make an impact and help people?

PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.

Diversity and Inclusion : PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths.

Supervise the functions of Grievance and Appeals (A&G) analysts and administrative support staff. Responsible for training, daily oversight, queue monitoring and caseload supervision of A&G analysts.

Provide assistance and guidance to internal and external customers regarding grievance / appeals policies and procedures.

Ensure customer satisfaction and help establish best practices.

Essential Responsibilities :

• Monitor caseload and queue activity of A&G Analysts, ensuring that deadlines are met and correct procedures are followed in accordance with regulatory and organizational requirements.
• Oversee auditing of grievance and appeal files for completeness of information; follow up with analysts to implement action plans for correcting errors or processes.
• Maintain staff schedules that align with the needs or the organization, in order to maintain appropriate coverage, and ensure compliance with regulatory requirements.
• Review and monitor overtime requests and utilization.
• Motivate the A&G team to provide high quality customer service internally and externally while maintaining regulatory standards.
• Maintain effective processes.
• Periodically review operations for efficiency and accuracy.
• Make recommendations to the A&G Manager of ways the department processes can be enhanced.
• Facilitate routine team meetings ensuring meeting minutes and attendees are captured and stored.
• Conduct regular one-one meeting with direct reports.
• Conduct timely performance evaluations and mediate interpersonal problems.
• Make recommendations to the A&G Manager concerning staffing issues and assist with follow through of corrective actions.
• Work collaboratively with A&G Manager to maintain policies and procedures, training material, and other communication materials.
• Coordinate business activities by maintaining collaborative partnerships with key departments.
• Assist with hiring, staff development, coaching, performance reviews, corrective actions, and termination of employees.
• Actively participate as a key team member in department meetings.
• Actively participate in various strategic and internal committees in order to disseminate information within the organization and represent company philosophy.

Supporting Responsibilities :

• Provide backup for grievance and appeals staff as needed.
• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Meet department and company performance and attendance expectations.
• Perform other duties as assigned.

Work Experience : Minimum three years of experience in the healthcare or health insurance industry. Active problem resolution and people management experience preferred.

Experience in Grievance and Appeals processes preferred.

Education, Certificates, Licenses : High school diploma or equivalent required. Bachelor’s degree preferred.

Knowledge : Strong knowledge of Medicare / Medicaid benefits, program structure and HIPAA laws / regulations. Strong understanding of grievance / appeal regulations for Medicaid and Medicare programs.

Intermediate-advanced proficiency in Microsoft Office Applications including Word and Excel and call tracking software, mainframe and medical management software.

Basic-intermediate knowledge of medical terminology and medical coding. Knowledge of claims, authorization methodology, and provider networks.

Excellent business writing skills. Excellent time management and diplomatic skills. Excellent communication style with subordinates, colleagues and other business partners.

Bilingual (Spanish) preferred.

Competencies : Building Trust

Building Trust

Building a Successful Team

Aligning Performance for Success

Building Customer Loyalty

Building Strategic Work Relationships

Continuous Improvement

Decision Making

Facilitating Change

Leveraging Diversity

Driving for Results

Environment : Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 10% of the time.

Skills :

Accountable leadership, Communication, Communication (written / verbal), Critical Thinking, Decision Making, Influencing, Listening (active), Organizational skills / Planning and Organization

Our Values

We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business :

• We are committed to doing the right thing.
• We are one team working toward a common goal.
• We are each responsible for customer service.
• We practice open communication at all levels of the company to foster individual, team and company growth.
• We actively participate in efforts to improve our many communities-internally and externally.
• We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.
• We encourage creativity, innovation, and the pursuit of excellence.

Physical Requirements : Stoop and bend. Sit and / or stand for extended periods of time while performing core job functions.

Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English.

Communicate clearly and effectively.

Disclaimer : This job description indicates the general nature and level of work performed by employees within this position and is subject to change.

It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position.

Employment remains AT-WILL at all times.