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Why This Role is Important to Us:

Position Summary:

Reporting to the Director of Appeals & Grievances, the Manager, Appeals & Grievances (A&G) Audit and Oversight is responsible for the oversight of Plan level appeals and grievances within the Appeals & Grievances Department and delegated entities. The manager will work to ensures complaints and complex issues are investigated and resolved using regulatory guidance across all lines of business. This role provides direct supervision to staff to perform quality assurance reviews and delegate oversight to comply with CCA Standard Operating Procedures (SOPs) and applicable NCQA standards, CMS, MassHealth and other state or federal regulatory requirements.

This position will partner with other A&G leadership and leadership from around CCA to innovate A&G operations to support an Audit Ready quality standard for timeliness, accuracy, and documentation of complaints. The manager will be a role model for integrity and will establish and maintain effective professional work relationships, working collaboratively with all levels of management and business owners to help guide the discipline of planning, organizing, securing, managing, leading, and controlling resources to achieve goals specific to the Appeals & Grievances department

Supervision Exercised:

Yes, which includes but is not limited to providing leadership, work direction, and performance feedback to subordinate staff.

What You'll Be Doing:

Essential Duties & Responsibilities:

• Effectively manage a team to ensure a positive team environment, conduct performance reviews to provide feedback and development opportunities. This includes overseeing daily workflow, assess workloads and adjust as necessary to ensure work is completed timely and in compliance.

• Leads and represents Member Appeals and Grievances-relatedexternal CMS audits, NCQA Standards, state audit and/or internal audit.

• Oversees and participates in the regular review of internal dashboards and universes for accuracy and timeliness of core and delegated operations.

• Development of A&G case review and oversight program.

Conduct quality assurance reviews according to the policies and procedures as assigned by the Director. Partner with A&G Operations Manager and the A&G Clinical Manager to performroot cause analysis of identified issues to ensure accuracy of departmental processes and identify, when needed, process improvement opportunities. Assemble,

• track, and trend any necessary Corrective Action Plans, Mitigation strategies and associated impact analysis.

• Lead, participate and provide representation of the A&G operation at Internal and External meetings/ workgroups and acts as the point person to A&G operations specific to quality assurance, operational oversight, and compliance.

• Develop and execute on strategic opportunities to improve appeals & grievance process to support a best-in-class A&G operation that is efficient and effective in managing member appeals.

• Work collaboratively within Appeals and Grievances with key internal partners to build a high functioning, results oriented operation that supports an Audit Ready quality standard for timeliness, accuracy, and documentation of complaints.

• Propose and participate in training based upon quality assurance review results. Ensures operating manuals and procedural documents stay current when regulatory changes to maintain compliance with applicable NCQA standards, CMS, MassHealth and other state or federal regulatory requirements.

• Manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports.

• Performs other duties as they are assigned to meet department performance goals and to respond to changing priorities including administrative related tasks.

What We're Looking For:

Required Education (must have):

• Bachelor's Degree or combination of education & equivalent experience

• 5-7 years A&G Experience

• Previous Supervisory or Manager experience in AG or Customer Service in a healthcare environment

Required Knowledge, Skills & Abilities (must have):

• Proven ability to learn and implement regulations

• Excellent communication skills

• Strong analytical and problem-solving skills when working with larger data sets

• Directs a team, or several teams of colleagues through project lifecycles

• Initiates change of direction when problems are detected and provides possible solutions.

• Working knowledge with various technologies is preferrable

• Knowledge of Microsoft suite of products

Required Language (must have):

• English

Desired Experience (nice to have):

Previous experience in documentation creation & high attention to detail

EEO is The Law

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled

Please note employment with CCA is contingent upon acceptable professional references, a background check (including Mass CORI, employment, education, criminal check, and driving record, (if applicable)), an OIG Report and verification of a valid MA/RN license (if applicable). Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.