Supervisor Grievance & Appeals Operations

Supervisor Grievance & Appeals Operations Remote Full-Time About SCAN SCAN Group is a not-for-profit organization dedicated to tackling the most pressing issues facing older adults in the United States. SCAN Group is the sole corporate member of SCAN Health Plan, one of the nation's leading not-for-profit Medicare Advantage plans, serving more than 270,000 members in California, Arizona, and Nevada. SCAN has been a mission-driven organization dedicated to keeping seniors healthy and independent for more than 40 years and is known throughout the healthcare industry and nationally as a leading expert in senior healthcare. SCAN employees are a group of talented, passionate professionals who are committed to supporting older adults on their aging journey, while also innovating healthcare for seniors everywhere. Employees are provided with in-depth training and access to state-of-the-art tools necessary to do their jobs, as well as development and growth opportunities. SCAN takes great pride in recognizing our team members as experts in their fields and rewarding them for their efforts. The job Ensures regulatory compliance in the processing of all complaints, grievances and appeals in that all cases are processed in accordance with state and federal agency requirements as well as SCAN Health Plan's internal policies and procedures. You Will Supervise and coordinate the day-to-day operations of the Grievance & Appeals coordinator staff. Train staff in the key departmental functions, including but not limited to: departmental policies and procedures, CMS and DHCS regulations, yearly plan's benefits, review of cases assigned for Medi-Care Part C and Part D; correct classification of cases and the preparation of cases for review by a Pharmacist or Medical Director according to SCAN and Grievance and Appeals department policies and procedures to achieve organizational goals and outcomes. Check for and monitor understanding of all regulatory requirements and practices to meet department metrics, activities and interventions impacting 5 STAR and compliance measures. Ensure staff performance by being a resource for the team, resolving day-to-day issues, and problem solving issues related to case processes and case closures. Ensure staff completion of required activities (e.g. CTMs, ALJs, grievances and appeal functions) within the required timeframes by monitoring caseloads for turnaround times. Ensure compliance with and adhere to all regulatory and quality standards including but not limited to: Centers for Medicare and Medicaid Services (CMS), Department of Managed Health Care (DMHC), Department of Health Care Services (DHCS), and Department of Managed Health Care (DMHC) as it relates to the Grievance and Appeal Department activities by establishing and maintaining processes, checking for understanding, training, monitoring adherence to the standards, and by performing necessary process improvements to address areas of identified non-compliance. Develop and implement department policies, desktop procedures, workflows, job aids and training material. Recognize problems impacting Grievance and Appeals Department and develop solutions and either implement or discuss with direct report(s) as required. Prepare reports and statistics pertaining to grievances and appeals on a monthly and/or as needed basis, for submission to management, and regulatory agencies as required. Maintain staff by recruiting, selecting, orienting, and training employees; maintaining a safe and secure work environment; developing personal growth opportunities. Accomplish staff results by communicating job expectations; planning, monitoring, and appraising job results; coaching, counseling, and disciplining employees; initiating, coordinating, and enforcing systems, policies, and procedures. Actively support the achievement of SCAN's Vision and Goals. Other duties as assigned. Your qualifications Supervises/Manages Others (i.e. hires, performance reviews, corrective action, etc.) Required: Bachelor's Degree in Healthcare, Business or related field of study 2+ years combined experience in grievance and appeal, internal audit, healthcare industry audit, compliance and/or operations 2+ years supervisory experience in managed care setting highly preferred. Excellent presentation skills, group motivation and supervisory skills. Ability to research, analyze and solve problems. Demonstrates keen attention to detail and produces high quality work products. Ability to prioritize multiple and competing tasks, work independently and in a team environment. Ability to work well in a fast-paced and dynamic environment. Strong interpersonal skills, including excellent written and verbal communication skills. Strong organizational skills; Ability to multitask. Ability to apply strong analytical and critical thinking skills, required. Working knowledge of guidelines and regulations relevant to Grievance and Appeals including Medicare, Medi-Cal, DMHC, DHCS and NCQA guidelines appropriately maintain confidentiality. What's in it for you? Base Salary range:

$64,000.00

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$102,400.00 An annual employee bonus program Robust Wellness Program Generous paid-time-off (PTO) Eleven paid holidays per year, plus 1 additional floating holiday Excellent 401(k) Retirement Saving Plan with employer match. Robust employee recognition program Tuition reimbursement A work-life balance An opportunity to become part of a team that makes a difference to our members and our community every day! We're always looking for talented people to join our team! Qualified applicants are encouraged to apply now! At SCAN we believe that it is our business to improve the state of our world. Each of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits, and more. SCAN is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.

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