Supervisor Appeals and Grievances
US-CA-BAKERSFIELD
commonspirit_careers
Req #: 464127
Type: Day
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Overview: The purpose of Dignity Health Management Services Organization (Dignity Health MSO) is to build a system-wide integrated physician-centric, full-service management service organization structure. We offer a menu of management and business services that will leverage economies of scale across provider types and geographies and will lead the effort in developing Dignity Health's Medicaid population health care management pathways. Dignity Health MSO is dedicated to providing quality managed care administrative and clinical services to medical groups, hospitals, health plans and employers with a business objective to excel in coordinating patient care in a manner that supports containing costs while continually improving quality of care and levels of service. Dignity Health MSO accomplishes this by capitalizing on industry-leading technology and integrated administrative systems powered by local human resources that put patient care first. Dignity Health MSO offers an outstanding Total Rewards package that integrates competitive pay with a state-of-the-art, flexible Health & Welfare benefits package. Our cafeteria-style benefit program gives employees the ability to choose the benefits they want from a variety of options, including medical, dental and vision plans, for the employee and their dependents, Health Spending Account (HSA), Life Insurance and Long Term Disability. We also offer a 401k retirement plan with a generous employer-match. Other benefits include Paid Time Off and Sick Leave. One Community. One Mission. One California Responsibilities: The Appeals and Grievances Supervisor is responsible for managing and coordinating the appeals and grievance process within Dignity Health MSO. The Supervisor will lead a team of coordinators providing guidance, training, and support to ensure the highest standards of patient service and regulatory compliance. This role involves handling member and provider complaints, ensuring compliance with regulatory requirements, and facilitating timely and effective resolution of appeals and grievances. Acting a subject matter expert (SME), the Supervisor will work closely with internal teams and external stakeholders to ensure a high level of service and satisfaction. The Supervisor oversees a mix of operational, business and regulatory activities related to several Health Plan Partnerships. This position will work closely with health plan partners to ensure a seamless transition in implementing new and ongoing regulatory requirements. From a business perspective, this role is responsible for the ongoing delegation and performance of our contractual obligations. - Supervise a team of appeals and grievances coordinators. Develop and implement strategies to improve team performance and efficiency. - Receive, document, and manage member and provider appeals and grievances in accordance with Dignity Health MSOs organizational policies and regulatory standards. Ensure all cases are processed within required timeframes and follow-up actions are completed properly. Prepare and present reports on appeals and grievances activity to senior management. - Maintain detailed and accurate records of all appeals and grievances, including documentation of investigations, outcome, and communications. - Manages and works closely with Regulatory partners in the management of identified patient populations. Oversees a mix of operational, clinical, educational and business activities as they relate to this partnership. - Conducts relevant research into complaints and collaborates, coordinates and communicates with various departments (i.e. Member Services, Care Management, Claims), as well as external entities (i.e. Providers and Vendors) to collect additional information as necessary. - Monitor and analyze trends in appeals and grievances to identify systemic issues and recommend corrective actions. Prepare and submit regular reporting on appeals and grievance activity, trends, and outcomes to management and regulatory agencies as required. ***This position is remote within California. Qualifications: Minimum Qualifications: - 3+ years of experience in healthcare appeals and grievances, with at least 2 years in a supervisory or leadership role. - Associates degree or 3 years of related job or industry experience in lieu of degree. - Familiarity with healthcare regulations, including HIPAA, CMS, and state-specific requirements. Preferred Qualifications: - Previous appeals and grievances experience at a health plan, managed care organization and IPA strongly preferred. - Previous experience in claims, UM or provider relations a plus. - Bachelors degree in a relevant field (e.g., healthcare management, business administration, compliance) or 5 years of related job or industry experience in lieu of degree preferred. - Knowledge of DMHC, NCQA, CMS and other regulatory bodies preferred. - Strong technical proficiency in data analysis; database software preferred. - Regulatory audit experience preferred. - Certified Compliance Professional, Certified Professional in Healthcare Quality, or Certified Healthcare Auditor preferred. #LI-DH
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