Supervisor Appeals & Grievances Job at AmeriHealth Caritas
Your career starts now. We’re looking for the next generation of health care leaders.
At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.
Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com.
Responsibilities:
Under the direction of the Manager, Appeals & Grievances, the Supervisor will oversee the appeal intake and grievance processes, ensuring compliance with all State and other mandated guidelines. Inform appropriate staff of requirements and recommendations regarding company policies and initiatives, and ensure proper implementation. Coordinate with other departments such as, clinical, account executives and member services staff regarding appeal and grievance related activities. Produce statutory reports related to appeals and grievances. The Supervisor, Appeals & Grievances will also be held accountable for the following:
- Manage daily operations and the processing of all grievances, and the intake for appeals, ensuring their completion in a manner which meets all mandated requirements
- Supervision of Coordinator Appeals & Grievances and Clinical Appeals Reviewers.
- Maintain familiarity and compliance with federal, state and local regulations as well as other regulatory requirements (e.g. NCQA standards) relative to appeal and grievance operations.
- Review report on trends related to appeals & grievances.
- Support staff and departments with resolving appropriate procedural issues that affect maintaining effective operations.
- Provide training to departments, State and consumer representatives.
- Conduct documentation audits to ensure to adherence to quality assurance standards for quality documentation.
Education/ Experience:
- Bachelor’s Degree desired or equivalent combination of educational background and experience.
- 3 to 5 years supervisory experience required in a managed care environment.
- Minimum of one year of experience in appeals or grievances preferred. Clinical background preferred.
- Strong customer service background required.
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