ABOUT THE ROLE

The Appeals and Grievances Manager 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 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.

YOUR RESPONSIBILITIES

• Leads, organizes, 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 law
• Develop and maintain 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
• Define and maintain Bright’s Appeals and Grievances process to ensure regulatory compliance and consumer experience
• Create the appropriate business requirement documents for 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
• Achieve turn-around time and quality metrics to ensure regulatory compliance and optimal administrative STAR ratings
• Train appeals and grievances staff, customer/member services department, sales, UM, and other departments within Bright Health (and delegates) on early recognition and timely routing of member complaints
• Train and manage Appeals and Grievances analyst staff to ensure high-quality case resolution of non-delegated, escalated, and regulatory cases
• Maintain systems for tracking appeals and grievances data and manage the completed case repository for regulator audit preparedness
• Manage system permissions for appeals and grievances staff and acquire access to systems needed for the team to complete the team’s work
• 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
• Serve as primary Appeals & Grievances contact to internal and external stakeholders
• Handle member, regulator, or other parties-to-a-complaint phone calls that escalate beyond the handling of the Appeals and Grievances analyst and maintain the highest quality customer service possible.

SUPERVISORY RESPONSIBILITIES

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

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE

• Bachelor’s degree preferred, 10 years insurance experience
• Seven (7) or more years of experience in Appeals and Grievances
• Four (4) or more years management experience and proven leadership qualities

PROFESSIONAL COMPETENCIES

• Detail oriented
• Thrive in a fast-paced environment
• Excels at creating structure and bringing operational rigor to teams; passion for creating an effective team environment and resolving conflicts
• Self-directed and able to prioritize work appropriately and take ownership to drive results
• Ability to develop a cohesive team culture and develop team members.

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: Great Places to Work, Modern Healthcare, Forbes, etc. But more than anything, we're a group of people who are really dedicated to our mission in healthcare. Come join our growing 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!