The Supervisor Grievance and Appeals is responsible for daily operations of GARS and supervision of staff. The incumbent will provide necessary training and guidance to the staff as needed, and will work closely with the trainer, departmental audit team and business analyst to identify training opportunities, patterns and trends from the complaints and opportunities to streamline and improve processes. The incumbent will notify managers and director of findings. The incumbent is responsible for staying up to date on the latest information about CalOptima’s member benefits, regulatory changes and ensure adherence to established policies and procedures regarding the appeals and grievance process.
POSITION RESPONSIBILITIES:
- Supervises and manages the performance of the Resolution Specialist and/or Program Assistant teams.
- Monitors team performance and trends, and coach staff to ensure adherence to policy, procedure, and the highest level of customer service.
- Manages case inventory to ensure regulatory and departmental standards are met.
- Writes and delivers job performance evaluations for staff; responsible for the professional and performance development of the staff.
- Assists in the hiring process and provides ongoing staff training as needed.
- Handles escalated member or provider cases/calls as needed.
- Responsible for prompt communication with staff. Conducts monthly unit meetings to go over any changes to programs or training issues.
- Facilitates one-on-one meetings with staff to go over their monthly progress regarding performance.
- Sets or recommends work performance standards; collaborates with staff to determine assignment priorities.
- Reviews work procedures and recommend or change procedures to be efficient.
- Recognizes and resolves problems impacting the department processes by collecting and analyzing information; communicates suggestions to management and develops/implements solutions as appropriate.
- Assist with special projects and other duties as assigned by management.
Required Skills
- Communicate both in verbal and written formats.
- Work independently and with minimal supervision with highly confidential information per HIPAA regulations.
- Manage the tracking of multiple tasks in an efficient manner to ensure completion of all assigned projects.
- Establish and maintain effective interpersonal relationships with all levels of staff, other programs, agencies, and the public.
- Encourage the quality performance and development of subordinate staff.
- Plan, organize and prioritize work.
- Work under pressure resulting from type of work and deadlines.
- Utilize computer and appropriate software (e.g., Microsoft Office Suite) and job-specific applications/systems.
Required Experience
EXPERIENCE & EDUCATION:
- High school diploma or equivalent required; Bachelor’s degree preferred.
- 3 years of health care management experience, preferably in managed care environment in related area of responsibility, i.e. utilization management, quality management, customer service, grievances and appeals, required.
- 1 year of supervisory or lead work experience preferred.
- HMO, Medi-Cal/Medicaid, Medicare and health services experience preferred.
- Bilingual in one of CalOptima's defined threshold language is preferred.
KNOWLEDGE OF:
- Medi-Cal and Medicare program regulations, including State and Federal standards and regulations for member and provider rights and responsibilities.
- Principles and practices of the managed health care systems, and medical administration and NCQA Accreditation standards.
Grade: M
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