Director, Appeals and Grievances at Bright Health
- 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.
- 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.
- 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