Manager, Appeals and Grievances

| Remote
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!

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Technology we use

  • Engineering
  • Product
    • .NETLanguages
    • C#Languages
    • JavascriptLanguages
    • PythonLanguages
    • SqlLanguages
    • PowerShellLanguages
    • D3JSLibraries
    • ReactLibraries
    • Node.jsFrameworks
    • MongoDBDatabases
    • TSQLDatabases
    • InVisionDesign
    • SketchDesign
    • Lucid ChartDesign
    • JIRAManagement
    • Microsoft ProjectManagement

Location

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

An Insider's view of Bright Health

What’s the vibe like in the office?

The office has a relaxed and laid back vibe but people are very serious about their work - perfect!

Anthony

Data Engineer

What does your typical day look like?

My day is so varied, given how quickly we're growing, which is fulfilling for me. I have a good balance of strategic and tactical work in my day as well as time to focus and time to collaborate.

Jen

VP, Digital

What makes someone successful on your team?

A hard-working team player who thinks first and codes next is likely to learn a lot and quickly become a valuable member of the team. Lots of experience with some of our tooling is always nice, but if someone can't knowledge-share well or responds poorly to code reviews and other requests for collaboration, it'll be a tough fit.

Brian

Software Engineer 3

How do you make yourself accessible to the rest of the team?

Modeling after my manager, I like to provide both regularly scheduled one-on-one meetings, where developers and engineers get to set the agenda. We can talk about career development, design and architecture ideas, industry trends, or traditional HR topics like goal setting. It’s up to them. I also have begun setting regular “office hours.”

Amy

VP & Data Platform Architect

How do your team's ideas influence the company's direction?

We hire smart individuals who thrive on accomplishment and purpose. Our teams are exposed to the bigger picture through constant communication and dialogues – that encourages them to come up with innovative solutions to problems. We've made significant adjustments on our direction in technology and process that were initiated by the team.

Abdullah

VP, Engineering

What are Bright Health Perks + Benefits

Bright Health Benefits Overview

We have 3 different health insurance plans, all through Cigna (HDP, Premium HDP and PPO). We cover the majority of the cost for the employee and some cost for family. We have two dental plans and a vision plan as well. We put 3% of your total earnings into your 401K plan and you are immediately vested in that. We have all the latest technology (Mac or Surface laptops – your choice) to use including standing desks. Fully stocked fridge with snacks and drinks.

Culture
Friends outside of work
Eat lunch together
Daily stand up
Open door policy
Team owned deliverables
Team based strategic planning
Pair programming
Open office floor plan
Diversity
Highly diverse management team
Mean gender pay gap below 10%
Health Insurance & Wellness Benefits
Flexible Spending Account (FSA)
Bright Health employees can contribute up to $3500 annually to their FSA.
Disability Insurance
Dental Benefits
Vision Benefits
Health Insurance Benefits
Life Insurance
Onsite Gym
Retirement & Stock Options Benefits
401(K)
We will put 3% of your total earnings into your 401K plan, even if you don't put anything in. It's a safe harbor contribution.
401(K) Matching
Bright Health provides employees with a 401(k) plan managed by Vanguard. We provide a ‘safe harbor’ non-elective contribution equal to 3% of your compensation, regardless of participation in the p
Company Equity
Performance Bonus
Child Care & Parental Leave Benefits
Generous Parental Leave
We provide up to 6 weeks of parental leave for the primary caretaker. We also provide 2 weeks of leave for the secondary caretaker.
Flexible Work Schedule
Bright Health provides employees with a flexible work schedule that includes Core hours, Flexible start and end times.
Family Medical Leave
Employees who have been with the company for 12 months are eligible for 12 weeks of family medical leave.
Company sponsored family events
Bright Health sponsors family oriented events Annually.
Vacation & Time Off Benefits
Paid Holidays
Perks & Discounts
Casual Dress
Commuter Benefits
Stocked Kitchen
Happy Hours
Happy hours are hosted on occasion.
Fitness Subsidies
Bright Health employees are eligible for discounts on several gym memberships.
Professional Development Benefits
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