Manager Appeals & Grievance -Quality Management Job

Job Title:
Manager Appeals & Grievance -Quality Management
Job ID:
10222
Location: Virginia Beach, VA

Full/Part Time:
Full-Time
Regular/Temporary:
Regular

JOB SUMMARY: The position monitors and manages the regulatory compliance and operations activities of AMERIGROUP's Medical Necessity Appeals and Complaints tracking. The Manager focuses on AMERIGROUP's regulatory/contractual obligations of the multiple state regulatory bodies. Requires frequent monitoring and problem solving with the Health Plans and Corporate entities to ensure regulatory and accreditation needs are met. This position manages the associates in the Complaints and Grievances component of the QI department.

PRIMARY RESPONSIBILITIES:
1. Manage the Medical Necessity Appeals (MNA) and Complaints process and reporting:
· Provide management with information and tools for strategic planning and decision making.
· AGP corporate liaison with Health Plans and corporate entities and Regulatory for complaint tracking and MNA.
· Maintain productive working relationships with key regulators and Health Plan contacts that leads to a collaboration benefiting company operations and activity.
· Subject matter expert/advisor on MNA and complaints requirements and programs.
· Oversight of all MNA activity including MNA external review, advanced Appeal Hearings, Accreditation compliance and policies associated with these processes.
2. Assess, communicate and ensure associate understanding of state and federal regulations, legislation and regulatory requirements that impact business activity and operations.
3. Develop and maintain resource tools for internal education, and compliance assessments.
4. Work with AMERIGROUP Compliance to help with AGP and vendor preparations for performance assessments, and audits-
· Prepare AGP and vendor operational leads for targeted audit activity.
· Coordinate and organize desk review submissions and on-site audit materials.
· Lead on-site assessment and audit activity, if needed.
· Facilitate development of corrective action plans ("CAPs") and oversee CAP implementation.
· Interact with individual Health Plan audit and enforcement agencies to correct deficiencies and minimize administrative actions and sanction activity.
5. Manage submissions of reports for MNA and complaints/grievances to the appropriate committees and internal departments, as needed.
6. Provide feedback on regulatory filings and member correspondence pertaining to MNA and complaint management.
7. Oversee expansions and new market activities from an operational perspective, developing processes and policies to support the RFP, regulations, or EQRO requirements.
· Subject matter expert/advisor on MNA and complaint requirements and programs.
8. Provide leadership and motivation by establishing clear expectations, communicating specific performance feedback and providing timely and thorough performance appraisals.
· Interview, hire and train support staff
· Counsel support staff and take appropriate disciplinary action.
· Develop and administer team objectives, priorities and strategic action plans for achieving goals.

EDUCATION AND EXPERIENCE:
Education
Required:
· Bachelor's degree. Experience in lieu of degree is acceptable
· Experience with medical necessity appeals process and regulation.
Preferred : RN with managed care appeals and grievances experience.
Years and Type of Experience Required:

Required:
· 5 years of relevant work experience, to include HMO/Managed Care industry experience
· 3 years compliance with regulatory body(s) experience
· 3 years of leadership/management experience
· Extensive knowledge of federal and state HMO and Managed care regulations

Preferred:
· 1-2 years experience managing appeals and/or complaint processes for large company
· Extensive knowledge of accreditation requirements for MNA and complaints

Preferred:
Specific Technical Skills
Required:
· Intermediate level Microsoft Office Suite skills. Specifically Word and Excel.
· Report development skills including detail needed for specific market and summary for executive reporting..
Preferred: Report presentation skills for small and large groups
Certifications or Licensure
Required: None
Preferred: Registered Nurse (RN)
Other
Required:
· Strong analytical and organizational skills.
· Strong verbal and written communication skills.
· Ability to analyze, interpret, and summarize contracts, regulations, policies/procedures, reports and legal documents.
· Ability to respond to questions/concern from internal customers and regulatory agencies.
· Present company position in understandable and unambiguous manner in formal and informal presentations.
· Problem-solver - identify root cause, recommend options and implement/negotiate appropriate solutions.
· Strong team building skills.
· Ability to effectively set priorities and meet commitments.
· Ability to work under pressure and within strict time frames.
· Comfortable interfacing at all levels of the organization.
· Appreciation of cultural diversity and sensitivity towards target population.

SCOPE INFORMATION

Item Measure
· # Direct Reports - 0-5
· # Indirect Reports - 1-10
· Budgetary $ Responsibility -

PHYSICAL REQUIREMENTS
· Must be able to operate a computer and a telephone.
· Manual dexterity to access filing systems.
· Must be able to conduct, facilitate, and actively participate in meetings.
· Periodic travel required - must be able to travel on common carrier.

Equal Employment Opportunity

In accordance with state and federal laws, employment offers are tendered solely on the basis of qualifications without regard to race, religion, color, national origin, age, sex, marital status, sexual orientation, handicap (including disabled veterans) or Vietnam Era veteran status.

AMERIGROUP administers pre-employment drug testing as a condition of employment and a satisfactory criminal history background report.

Nearest Major Market: Virginia Beach
Job Segments: Management, Manager