Manager, Appeals and Grievances

About This Role

Lead a team responsible for processing Member Appeals and Grievances for Medicaid and Commercial product lines, ensuring compliance with state and federal regulations and optimizing departmental performance.

Responsibilities

• Oversee all processes related to the intake, triaging, coordination, and documentation of all appeals and grievances.
• Maintain quality control processes that ensure all standards for timely acknowledgment, resolution, and documentation standards are consistently met.
• Responsible for maintaining and updating annually at a minimum: appeal and grievance policies and procedures and rights, member correspondence materials, and process manuals consistent with regulatory or contractual changes.
• Leads the appeals and grievances team, including hiring, training, and evaluating staff performance.
• Develops and implements policies and procedures to ensure compliance with payer guidelines and regulatory requirements.
• Ensure timely appeal and grievance reporting to regulatory agencies and contracted clients.
• Collaborate with internal departments as necessary to ensure the timely resolution of all appeals and grievances.
• Present appeal and grievance reports and analysis to various internal stakeholders.
• Prepares for and is able to act as a spokesperson on all requests relating to appeals and grievances for state, federal, and quality audits.

Requirements

• At least 5-7 years of experience in appeals or grievances
• At least 2-3 years in a supervisory or management role
• Massachusetts Registered Nurse (RN) license
• Comprehensive knowledge of healthcare regulations, payer requirements, and billing practices
• Medicaid, Medicare, and Commercial insurance knowledge
• Ability to analyze large volume of data and synthesize for reporting purposes
• Strong leadership and team management abilities
• In-depth knowledge of payer appeals processes and claim denial management
• Excellent analytical and problem-solving skills for identifying trends and process improvements
• Proficiency in revenue cycle management tools and reporting systems
• Effective communication and interpersonal skills for collaboration and conflict resolution
• Ability to manage multiple priorities and ensure adherence to strict deadlines

Qualifications

• Bachelor's Degree or the equivalent combination of training and experience
• At least 5-7 years of experience in appeals or grievances and at least 2-3 years in a supervisory or management role.

Benefits