Resp & Qualifications
We are looking for an experienced people leader in Baltimore or surrounding counties who is willing and able to work in a hybrid model. The incumbent will be expected to work a portion of their week from home and at least two days a week at a CareFirst location based on business needs and work activities/deliverables that week.
Supervises and provides daily direction to the Government Programs Appeals and Grievance team members regarding staff scheduling, training and development; audits; policies, procedures, and work production quantity and quality. Oversight may include but not limited to: Maryland Medicaid and/or Medicare Advantage lines of businesses, operations and services related to appeals and grievances. Reviews and resolves complex operational and member support issues not resolvable by subordinates.
- Supervises employee outcomes by training, assigning, scheduling, coaching, and counseling employees; communicating job expectations; planning, monitoring, and appraising job contributions; conducting and overseeing audits; and ensuring adherence to policies, procedures and regulations.
- Meets operational standards by contributing information to strategic plans and reviews; implementing production, productivity, quality, and customer-service related standards; resolving people/process/technical problems; identifying system and/or process and workflow improvements. Supports the development of program descriptions, workflows, job aids and other SOPs related to appeals and grievance activities.
- Maintains departmental objectives by monitoring daily operations; resolving any issues that require manual review or technical support. Consistently supervises day to day clinical and non-clinical support operations and makes necessary adjustments where needed, including resources/staffing. Researches and resolves escalated cases, emails or telephone calls, review and resolves complex issues that have not been resolved by staff.
- Maintains and improves appeals and grievance operations by monitoring departmental and system performance; identifying and resolving problems; supervising process improvement and quality assurance programs; and supervises the process of conducting and following up on internal or external audits.
- Prepares performance reports by collecting, analyzing, and summarizing data and trends.
- Collaborates with members and/or family members, health care providers, community resource partners, and internal clinical and non-clinical colleagues to ensure effective service delivery and integration of member and provider focused appeals and grievance activities.
This position manages people - 8-10.
Education Level: High School Diploma or GED.
- 3 years related professional experience with demonstrated leadership skills.
- Must have proficiency in clinical support and/or member and health care provider outreach activities.
- Bachelor's Degree
- Proficiency in State or local regulations and/or compliance requirements related to healthcare delivery
- Proficiency in medical management software or electronic platforms related to appeals and grievance processes
Knowledge, Skills and Abilities (KSAs)
- Knowledge and experience in care coordination, clinical support, utilization view and/or member outreach operations.
- Ability to mentor and coach associates to accomplish goals, provide objective evaluation of associate performance, and implement strategies to improve individual and team-based performance as needed.
- Highly proficient in Microsoft Office programs including Word, Excel, and Power Point. Proficient in the use of web based electronic medical record or customer service systems.
- Excellent communication skills both written and verbal. Ability to positively influence other demonstrating respect and compassion. Strong presentation skills.
- Ability to plan, prioritize and organize work to meet changing priorities. Experienced with making decisions regarding work processes based on established guidelines.
- Demonstration of critical and innovating thinking, as well as change leadership.
- Compile, analyze, and organize data and information from multiple sources to carry out assignments and inform leadership on operational performance.
- Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Salary Range: $53,064 - $109,445
Salary Range Disclaimer
The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).
MD Medicaid -APPEALS & GRIEVANCE
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship