Director, Appeals and Grievances

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Making Healthcare Right. Together.” is the cornerstone of all we do. Our vision is through powerful relationships with Care Partners, we help all people live healthy and brighter lives. To successfully achieve our mission and vision as we operate in a dynamic health care environment, we expect Bright employees to embody and uphold our core values in work and interactions, both internal and external: be brave, be brilliant, be accountable, be inclusive, and be collaborative.


The Director, Appeals and Grievances is responsible for organizing and advancing Bright Health’s provider data infrastructure as it relates to roster management, data quality and accuracy, fee schedule builds, and integration with other Bright and third-party databases. This role is accountable for driving the company’s performance and strategy by ensuring timely, efficient, and accurate provider data and fee schedule flows throughout Bright Health. 

ROLE RESPONSIBILITIES

  • Determines strategy, designs compliant process and directs the activities of the Appeals & Grievances unit that is responsible for reviewing and resolving member complaints and communicating resolution to members or authorized representatives in accordance with state and federal laws.
  • Directs the development of business policies, procedures, workflows, and correspondence materials related to both the Medicare Advantage (Parts C and D) Appeals and Grievances operations and our state-based Individual and Family Plans (IFPs) Appeals and Grievances operations to ensure compliance with state and federal regulations. Develops training to policy and procedure.
  • Develops and directs quality and compliance programs to ensure performance monitoring, operational reporting, and regulatory reporting
  • Work with internal teams and delegated partners to implement, oversee, and manage any delegated A&G functions
  • Manage the configuration and customization of technology to meet business requirements
  • Develop and Maintain systems for tracking appeals and grievances data and manage the completed case repository for regulator audit, accreditation preparedness
  • Provide trend analysis to internal or external stakeholders, as necessary, to escalate issues to appropriate organizational decision makers
  • Provide internal and regulatory reporting, on a scheduled or ad-hoc basis, to stakeholders as requested
  • Other duties and responsibilities as assigned.

SUPERVISORY RESPONSIBILITIES

  • This position has supervisory responsibilities for members of the Appeals and Grievances team.

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE

  • Bachelor’s degree required, Master’s degree preferred.
  • Ten (10) or more years of professional experience required.
  • Seven (7) or more years of experience in a health plan setting preferred.
  • Five (5) or more years of supervisory experience required.

PROFESSIONAL COMPETENCIES

  • Ability to work independently as well as collaborate in groups
  • Strong skills in listening, verbal, and written communications
  • Ability to think innovatively and creatively solve problems; strong analytical skills
  • Excellent customer service skills with internal and external stakeholders

ABOUT US

 

At Bright Health, we brought together the brightest minds from the health care industry and consumer technology, and together we created Bright Health: a new, brighter approach to healthcare, built for individuals. Our plans are easy to manage, personalized, and more affordable, giving people the quality care they deserve. Through our exclusive care partnerships with leading health systems in local communities, we are reshaping how people and physicians achieve better health together.

 

We’re Making Healthcare Right. Together. 


We've won some fun awards like Modern Healthcare and Forbes, etc. But more than anything, we're a group of people who are really dedicated to our mission in healthcare. Come join our team!

 

As an Equal Opportunity Employer, we welcome and employ a diverse employee group committed to meeting the needs of Bright Health, our consumers, and the communities we serve. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.


BRIGHT ON!

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Location

We are downtown at 515 Congress Avenue, right in the heart of downtown! Tons of restaurants and close to public transportation.

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