The Supervisor is responsible for overseeing the daily appeal and grievance process at Commonwealth Care Alliance (CCA) and management of A/G department. The candidate is responsible to provide daily direction, communication, and support to the team to facilitate timely identification, intervention and resolution of the complaint intake and reporting process for both the Senior Care Options (SCO) and One Care Programs. This position works collaboratively across many departments at CCA to facilitate timely resolution of all grievances and appeals and ensures compliance with regulators. In addition, this position either directly supervises the staff and the preparation of the data and regular reports to our external regulators as well as for internal committees and oversees the preparation of cases for Level I internal review of appeals, the Mass Board of Hearings, IRE, or ALJ. Overseeing the audit preparation and data validation is also part of the position.
The ideal candidate must have a minimum of three successful years as an Appeals & Grievance Coordinator or Specialist in a health care environment, preferably in a Medicare Managed Care organization. Additionally, the perfect candidate should have a minimum of one year supervisory experience or demonstrate leadership capabilities. The candidate must also possess effective collaboration, organizational, process improvement, and problem solving skills, as well as excellent written and verbal communication skills. The candidate must be able to exercise exceptional judgment in decision-making, meet deadlines, and to work independently and with flexibility. Exceptional attention to detail is required for the position. This position ensures the integrity and accuracy of complaint data and process used for tracking and quality improvements of the organization.Key Responsibilities
- Responsible for monitoring overall performance and productivity of the team and goals around quality and timeliness to meet contractual requirements, and facilitate interventions and coordination of actions by internal partners
- Leadership, Supervision, and Guidance: Supervises the day-to-day responsibilities of the A/G team. Provides guidance and leadership to the Appeal & Grievance Coordinator and Appeal/Grievances Representatives in processing complaint interventions and resolutions within the specified deadlines, data compilation, report completion, and data validation and audit preparation activities.
- External Communication: Represents CCA/CCC appeal and grievance data and trends to external regulators.
- Oversees and monitors activities to assess the progress of complaint interventions, resolutions, and adherence to timeframes/deadlines.
- Assure verbal and written responses are provided to members and/or providers within the required timeframes.
- Serve as a resource to assure timely completion of all external written correspondence and reports. Oversee internal or Level I review of appeals and support the coordination of CCA’s participation in the Mass Board of Hearings and IRE and assure that relevant documentation is provided in advance.
- Analyzes Data and Identifies Trends for Continuous Improvement Purposes: Regularly reviews and analyzes the data and identifies trends. Communicates findings to supervisors and other interested parties including staff working with third party vendors, such as the transportation and dental administrators, and CCA Provider Relations.
- Interdisciplinary Communication: Act as a liaison between multiple departments to ensure quality improvement measures as well the timely and complete capture and processing of all grievances and appeals. Interdepartmental stakeholders include but are not limited to: quality; regulatory affairs/compliance; clinical, operations, pharmacy, dental, reporting, and member services.
- Content Expert: Act as CCA’s content expert on State and Federal Grievance and Appeal regulations for all CCA products. Appropriately interpret, apply, and communicate CMS and State regulations. Remain apprised of policy updates and update operational processes, as necessary and assist in the update of CCA’s Appeal and Grievance Policy and Procedures as well as related Standard Operating Procedures.
- Monitor Data Compilation & Report Completion: Oversees the Appeals & Grievance Representatives in monitoring resolution of open grievances and appeals and complete all required regulatory reports in a timely fashion, including monthly state, quarterly CMS and CCA monthly dashboard and quarterly Quality Committee reports and presentations; work collaboratively with Quality Department on ‘quality of care’ grievances and incident report completion, review, and approval that are reported through the Member Services Department.
- Audits: Work with Regulatory Affairs & Compliance Department and other internal stakeholders in federal, state, and/or internal audits of grievance and appeals processes as well as data validation activities, as needed. Takes the lead in presenting Part C appeals and all grievance documentation during a mock or actual audit.
- Training: Prepares and delivers monthly trainings on ‘Appeal and Grievance Overview’ for the clinical and other operational and program staff at CCA.
- Creates and maintains a high quality and productive team environment to keep Appeals and Grievances team motivated to perform at their highest level.
- Evaluates staff performance and administers introductory and annual performance evaluation meetings as well as meetings to address performance and corrective action issues as appropriate.
- Assists staff with resolving problems, developing independence and use of resources, and using solid judgment skills.
- Manages daily staff assignments ensuring inquiries and requests are responded to and documented according to protocols.
- Demonstrates exemplary leadership, exceptional work ethic, ability to prioritize task; able to work under pressure and strive to find creative solution. Responsible for monitoring overall performance of the One Care program in meeting goals around quality, cost and access as well as all contractual requirements, and facilitating interventions and coordination of actions by internal partners across the organization.
- The candidate is responsible for management of staff and make performance management decisions such as staff evaluation or corrective action processes as needed.
Please note employment with CCA is contingent upon acceptable professional references, a background check (including Mass CORI, employment, education, criminal check, and driving record, (if applicable)), an OIG Report and verification of a valid MA/ RN license (if applicable).Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.
- Bachelor's Degree or equivalent experience.
- Bachelor’s Degree (B.S. or B.A.) or an Associate’s Degree with equivalent of at least one year of previous professional experience in a health care, case/care management administrative, or related position.
- Minimum years’ experience required 3-5 years.
- A minimum of three successful years as an Appeals & Grievance Coordinator or Specialist in a health care environment, preferably in a Medicare Managed Care organization.
- The perfect candidate should have a minimum of one year supervisory experience or demonstrate leadership capabilities.
- Ability to lead and supervise a team of professionals on their daily tasks and responsibilities that support the appeal and complaint process.
- Able to monitor overall performance and productivity of the team and goals around quality and timeliness to meet contractual requirements, and facilitate interventions and coordination of actions by internal partners.
- Thorough knowledge of Chapter 13 of the Medicare Managed Care Manual, HPMS, SCO and One Care contracts and other regulations as applicable.
- Must demonstrate leadership and initiative with a high degree of accountability and responsibility.
- Must demonstrate flexibility in terms of work completion and daily checking of external complaints reporting systems.
- Demonstrated exceptional written and verbal communication, presentation and interpersonal skills.