Manager, Grievance & Appeals
Core
Manage the day-to-day operations of the Grievance & Appeals department, ensuring processing of member and provider appeals in accordance with legal and contractual requirements.
Role type
Manager, Grievance & Appeals
Builds
Regulatory compliance processes for grievances and appeals
Domain
Healthcare administration / Regulatory compliance
Deliverable
dashboards & analysis
Required skills
Grievance and appeals processing, Regulatory compliance, Team management, Reporting and trend analysis, Contract interpretation, Incident report review
Preferred skills
Active RN licensure in Oregon, Experience in healthcare or law, Supervisory experience
Technologies
Regulatory systems
Responsibilities
Process member and provider appeals within required timeframes, Monitor appeals and provide monthly trend reports to senior management, Integrate federal and state law changes into the regulatory system, Work with external government constituencies, Recommend solutions to prevent recurrence of issues, Review incoming incident/accident reports