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The Program Manager is a key member of the Medicare Advantage Claims, Configuration and Appeals and Grievance Operations team. Assists in planning, developing, implementing, and managing the Medicare Advantage Claims, Appeals and Grievance program requirements, operational initiatives and policies.
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Interface with Grievance and Appeals, Claims, Enrollment, IT, Network Management, Pharmacy, Authorizations, and other internal departments to provide Service Excellence to our members.
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They will process appeals and grievances to facilitate the accurate administration of benefits and clinical policy; and ensure compliance of the appeal and grievance process with all regulatory requirements and NCQA standards.
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Research and resolve grievance and appeals for the commercial line of business, utilizing a higher level of adjudicator expertise, clinical interpretation and decision making.
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The incumbent reviews and analyzes key program, regulatory and operational performance indicators for the functional areas reporting to the Assistant Director, Medicare Advantage Operations and makes recommendations to the leadership team on strategies to improve performance.
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Engagement Description –The Grievance and Appeals (G&A) Coordinator is responsible for processing appeals, grievances, complaints, and inquiries received from members, authorized representatives, and regulatory agencies.
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Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievance and appeals (member/provider) via target system. The CSR guides the member through their members plan of benefits, Aetna policy and procedures as well as having knowledge of resources to comply with any regulatory guidelines.
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The Program Manager leads and manages key operational programs, initiatives and strategic projects that span across the functional teams of Claims, Configuration and Appeals and Grievances.
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The Grievance/Appeals Analyst I is an entry level position in the Enterprise Grievance & Appeals Department that reviews, analyzes and processes non-complex pre service and post service grievances and appeals requests from customer types (i.e. member, provider, regulatory and third party) and multiple products (i.e. HMO, POS, PPO, EPO, CDHP, and indemnity) related to clinical and non clinical services, quality of service, and quality of care issues to include executive and regulatory grievances.
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Along with the Assistant Director, Medicare Advantage Operations, the Program Manager is responsible for program management activities impacting the functional areas within the span of control of the Assistant Director including but not limited to initiation, planning, development, and monitoring of program implementations and day to day operations performance monitoring in order to ensure timeliness and compliance.
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The Grievance & Appeals Compliance Specialist, in coordination with Corporate Regulatory staff, ensures the Grievance & Appeals (G & A) team is in compliance with contract requirements and ensures that review, submission and required reporting deadlines are met.
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Gathers pertinent information regarding the grievances and appeals received, including, but not limited to, member or provider concerns, supporting information related to initial decision-making, new information supporting the grievance or appeal, or supplemental information required to evaluate grievances and appeals within regulatory requirements.
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Provides assistance and support to other departments, as needed, to obtain crucial or required information from Providers, such as HEDIS, Credentialing, Grievance and Appeals, SIU, etc.
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You will oversee the accurate, compliant, efficient, and timely configuration of claim benefits, regulatory and business rules, provider contracts, and appeals and grievance processing capabilities.
$67,400 - $133,400 a yearFull-timeExpandApply NowActive JobUpdated 4 days ago - UpvoteDownvoteShare Job
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Experience in Medicare Advantage Claims, Appeals & Grievances, program/project management. Our client, a Medical Center facility under the aegis of a California Public Ivy university and one of largest health delivery systems in California, seeks an accomplished Medicare Program Manager.
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grievance appeals and regulatory jobs
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