Cencal Health
Medicare Grievance and Appeals Manager
Cencal Health, Santa Barbara, California, us, 93190
Job Details
Job LocationMain Office - Santa Barbara, CA
Position TypeFull Time
Job CategoryMember Services
Description
California Salary Range:
The displayed compensation range of $112,000 - $120,000 per year reflects the pay scale that CenCal Health, in good faith, reasonably expects to pay for this specific position, considering prevailing circumstances at the time of the posting. It is important to note that CenCal Health reserves the right, as permitted by law, to adjust compensation either upwards or downwards from the indicated range.
Full-Time Hybrid Schedule:
1 Day/Week in Santa Barbara Office. Additional days in-office may be required as needed.
Location:
As a community-facing role, candidates must reside in or be willing to relocate to Ventura, Santa Barbara, San Luis Obispo, or Santa Cruz County.
Job Summary
The Medicare Grievance and Appeals Manager is a leadership role within the Member Services Department, specializing in the development and management of the Medicare Grievance and Appeals (G&A) function. This pivotal position is dedicated to ensuring compliance with regulatory requirements while enhancing the quality and effectiveness of the Medicare G&A processes. The Medicare Grievance and Appeals Manager possesses strong leadership skills, in-depth knowledge of Medicare regulations, and a commitment to delivering exceptional service to our members.
Duties and Responsibilities:Develop, implement, and manage the Medicare Grievance and Appeals program including for exclusively aligned products, ensuring compliance with Medicare regulations, CMS and DHCS guidelines, and organizational policies.Provide leadership and direction to a team of grievance and appeals specialists, fostering a culture of excellence, collaboration, and continuous improvement.Establish clear goals, performance metrics, and quality standards for the Medicare G&A function. Work with internal reporting resources to establish routine monitoring reports and routinely monitor performance to ensure targets are met or exceeded. Provide regular performance updates to senior leadership and any Quality Improvement and Population Health related committees.Serve as the subject matter expert on Medicare G&A processes, policies, and regulations, providing guidance and support to internal stakeholders including Member Services, Compliance, Legal, and Clinical teams.Collaborate with cross-functional teams to identify areas for process improvement and implement solutions to enhance the efficiency and effectiveness of the Medicare G&A function.Oversee the timely and accurate resolution of Medicare grievances and appeals, ensuring that members receive fair and thorough reviews of their concerns.Develop and deliver training programs for staff involved in Medicare G&A activities, ensuring that team members have the knowledge and skills needed to perform their roles effectively.Serve as the primary point of contact for CMS and other regulatory agencies regarding Medicare G&A matters, responding to inquiries, and facilitating audits or reviews as needed.Qualifications
Knowledge/Skills/Abilities
In-depth knowledge of Medicare regulations, CMS guidelines, and industry best practices related to Grievance and Appeals processes.Strong leadership and management skills, with experience leading teams and driving organizational change.Excellent communication and interpersonal skills, with the ability to effectively interact with internal and external stakeholders at all levels.Analytical mindset with the ability to interpret data, identify trends, and make data-driven decisions.Commitment to quality, accuracy, and compliance with regulatory requirements.Education and Experience
Bachelor's degree in Healthcare Administration, Business Administration, Nursing, or a related field, or an equivalent combination of education and experience.Master's degree preferred.Minimum of 5 years of experience in healthcare operations, with a focus on Medicare Grievance and Appeals management.
Job LocationMain Office - Santa Barbara, CA
Position TypeFull Time
Job CategoryMember Services
Description
California Salary Range:
The displayed compensation range of $112,000 - $120,000 per year reflects the pay scale that CenCal Health, in good faith, reasonably expects to pay for this specific position, considering prevailing circumstances at the time of the posting. It is important to note that CenCal Health reserves the right, as permitted by law, to adjust compensation either upwards or downwards from the indicated range.
Full-Time Hybrid Schedule:
1 Day/Week in Santa Barbara Office. Additional days in-office may be required as needed.
Location:
As a community-facing role, candidates must reside in or be willing to relocate to Ventura, Santa Barbara, San Luis Obispo, or Santa Cruz County.
Job Summary
The Medicare Grievance and Appeals Manager is a leadership role within the Member Services Department, specializing in the development and management of the Medicare Grievance and Appeals (G&A) function. This pivotal position is dedicated to ensuring compliance with regulatory requirements while enhancing the quality and effectiveness of the Medicare G&A processes. The Medicare Grievance and Appeals Manager possesses strong leadership skills, in-depth knowledge of Medicare regulations, and a commitment to delivering exceptional service to our members.
Duties and Responsibilities:Develop, implement, and manage the Medicare Grievance and Appeals program including for exclusively aligned products, ensuring compliance with Medicare regulations, CMS and DHCS guidelines, and organizational policies.Provide leadership and direction to a team of grievance and appeals specialists, fostering a culture of excellence, collaboration, and continuous improvement.Establish clear goals, performance metrics, and quality standards for the Medicare G&A function. Work with internal reporting resources to establish routine monitoring reports and routinely monitor performance to ensure targets are met or exceeded. Provide regular performance updates to senior leadership and any Quality Improvement and Population Health related committees.Serve as the subject matter expert on Medicare G&A processes, policies, and regulations, providing guidance and support to internal stakeholders including Member Services, Compliance, Legal, and Clinical teams.Collaborate with cross-functional teams to identify areas for process improvement and implement solutions to enhance the efficiency and effectiveness of the Medicare G&A function.Oversee the timely and accurate resolution of Medicare grievances and appeals, ensuring that members receive fair and thorough reviews of their concerns.Develop and deliver training programs for staff involved in Medicare G&A activities, ensuring that team members have the knowledge and skills needed to perform their roles effectively.Serve as the primary point of contact for CMS and other regulatory agencies regarding Medicare G&A matters, responding to inquiries, and facilitating audits or reviews as needed.Qualifications
Knowledge/Skills/Abilities
In-depth knowledge of Medicare regulations, CMS guidelines, and industry best practices related to Grievance and Appeals processes.Strong leadership and management skills, with experience leading teams and driving organizational change.Excellent communication and interpersonal skills, with the ability to effectively interact with internal and external stakeholders at all levels.Analytical mindset with the ability to interpret data, identify trends, and make data-driven decisions.Commitment to quality, accuracy, and compliance with regulatory requirements.Education and Experience
Bachelor's degree in Healthcare Administration, Business Administration, Nursing, or a related field, or an equivalent combination of education and experience.Master's degree preferred.Minimum of 5 years of experience in healthcare operations, with a focus on Medicare Grievance and Appeals management.