SCOPE OF ROLE

The Director, Appeals and Grievances oversees all Bright Health Appeals & Grievances operations, for all Bright product offerings, to ensure regulatory compliance and operational efficiency. This position is responsible for Bright employees in the processing and resolution of appeals and grievances cases, the accurate response to escalated inquiries and grievances, and oversight of delegates performing appeals and grievances functions on behalf of Bright Health. They are responsible for URAC, NCQA, CMS, Stars and State DOI positive outcomes.  In addition, they are responsible for timely and accurate review of changes in regulatory guidance affecting appeals and grievances operations, evaluating the operational impact of Bright entering new markets, and evaluating the operational impact of Bright increasing the scope of product offerings by market.

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.

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE

• Bachelor’s degree required, Master’s degree preferred.
• Ten (10) or more years of professional experience required; Five (5) years direct Appeals and Grievances experience.
• 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