Build the Possibilities. Make an extraordinary impact.
Responsible for ensuring the proper planning, directing, and evaluation of the investigation, resolution, and response to Medicare/Medicaid grievance and appeals.
How you will make an impact:
- Develops the goals, objectives, and policies for the assigned grievance and appeals function.
- Provides oversight, leadership, guidance and training to grievance and appeals programs to drive results, meet regulatory compliance and achieve targeted goals.
- Manages the development of systems and processes in support of program activities.
- Proactively manages inventory volumes ensuring compliance and the creation of data driven senior level reporting.
- Supports initiatives to improve root cause of grievances and appeals and implementing action plans for improvement.
- Ensures that processes and procedures support overall Quality Improvement program requirements, meets regulatory compliance, accreditation, audit and Company standards.
- Prepares, directs and supports audit functions to monitor efficiency and compliance with company policies and state and federal requirements.
- Provides quality control services by monitoring work results of direct reports.
- Analyzes and develops strategies to achieve performance thresholds within budgetary guidelines.
- Plans and executes financial objectives, significant budget accountability, forecasts staffing needs and manages special projects.
- Hires, trains, coaches, counsels, and evaluates performance of direct reports.
- Requires a Bachelors degree in a related field.
- Minimum of 5 years of managed care operations experience.
- Minimum of 5 years management/leadership experience; or any combination of education and experience which would provide an equivalent background.
- Some travel required - in office 4-10 times per month.
Preferred Skills, Capabilities and Experiences:
- Experience with Grievance & Appeals and delegate oversight preferred.
- Strong operational background preferred.
Please be advised that Elevance Health only accepts resumes from agencies that have a signed agreement with Elevance Health. Accordingly, Elevance Health is not obligated to pay referral fees to any agency that is not a party to an agreement with Elevance Health. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Be part of an Extraordinary Team
Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. A Fortune 20 company with a longstanding history in the healthcare industry, we are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Elevance Health approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Elevance Health is able to reasonably accommodate. Elevance Health will also follow all relevant federal, state and local laws.
Elevance Health has been named as a Fortune Great Place To Work in 2022, has been ranked for five years running as one of the 2023 World’s Most Admired Companies by Fortune magazine, and is a growing Top 20 Fortune 500 Company. To learn more about our company and apply, please visit us at careers.ElevanceHealth.com. Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact email@example.com for assistance.