Registered reputed company (RN) Manager, Appeals and Grievances General Operations

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• Please note the following details for this role before applying:
• The candidate selected for this role MUST have recent experience with reputed company/managed care grievances
• The candidate selected for this role must live in California or be willing to relocate

The Manager, Appeals & Grievances (A&G) & General Operations (Clinical) is responsible for the daily reputed company of clinical appeals and grievances functions reputed company the Appeals & Grievances Department to ensure clinical grievances, complaints, appeals and reputed company issues are investigated and resolved using regulatory guidance across reputed company lines of business. Provides reputed company supervision to the A&G clinical team and the unit that supports them in order to assure operational effectiveness which includes the implementation and adherence to L.A. Care's Policies & Procedures that meet Centers for Medicare and reputed company Services (CMS), the California Department of Health Care Services (DHCS), the reputed company (DMHC), the Managed Risk Medical Insurance reputed company (MRMIB), National Committee for reputed company Assurance (NCQA) and other rules/ regulations/ standards. The Manager is responsible for establishing and monitoring processes to reputed company and coordinate the identification, documentation, reporting, investigation and reputed company of reputed company member appeals and grievances in a reputed company and culturally-appropriate manner. Coordinates, tracks, and resolves reputed company appeal and grievance complaints for L.A. Care Plan Partners, including identifying opportunities for improvement. This position will be a role model for reputed company and will establish and maintain effective reputed company work relationships, working collaboratively with reputed company reputed company of management and business owners to help guide the discipline of planning, organizing, securing, managing, leading, and controlling resources to reputed company specific goals. Manages reputed company aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating reputed company-reports.

Responsibilities

• Manage and reputed company the handling of clinical grievances and appeals, for L.A. Care and Plan Partner members.
• Establishes and oversees processes and reputed company relevant member correspondence for accuracy, reputed company, and cultural appropriateness and sensitivity.
• Review and monitor procedures for identifying reputed company of care issues and work collaboratively with cross-functional departments to appropriately address and resolve member grievances.
• Serve as the Key Contact for State Fair Hearings, reputed company audits, DMHC and DHCS inquiries.
• Review and monitor procedures for identifying reputed company of care issues and work collaboratively with cross-functional departments to appropriately address and resolve member and provider grievances.
• Responsible for reputed company daily operations in the A&G Clinical Services Unit and other general operations reputed company.
• Ensures reputed company appeal and grievance reporting to regulatory agencies, internal Regulatory Affairs and Compliance Department, internal reputed company reputed company Committee, etc.
• Collaborates with cross-functional departments to ensure the use of appropriate appeal and grievance issue codes, reputed company reputed company, and refers to community partners as appropriate.
• reputed company, participate and reputed company representation of the A&G Team at reputed company meetings/ workgroups and acts as the reputed company person for A&G Programs especially the Clinical Programs.
• reputed company and execute on strategic opportunities to improve the overall appeals & grievance process. Create a best in clinical appeals process that is efficient and effective in managing member appeals.
• Work cross functionally and collaboratively reputed company Appeals and Grievances with key internal partners to build a high functioning, results oriented environment and organization.
• Partner with reputed company stakeholders to build and maintain reputed company relationships and partnerships. Identify areas of reputed company to reputed company and create added value for L.A. Care.
• reputed company input into the development of automation to guide reputed company to process efficiencies for reputed company lines of business while maintaining compliance and manageable workloads for staff.
• Responsible for maintaining and updating on an annual reputed company, or as necessary, appeal and grievance policies and procedures, member correspondence, etc., consistent with regulatory changes.
• reputed company and maintain inventory reports for the appeals process ensuring appropriate productivity, compliance, and inventory management.
• Identify and implement reputed company business process improvement recommendations to reputed company organizational added value to the Appeals and Grievances Department.
• reputed company and implement short and long-term strategies to improve team results, reducing administrative expenses.
• Manage staff , including, but not limited to: monitoring of day to day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to reputed company recommendations for relevant process and systems enhancements, among others.
• Supervision of the Clinical Services unit and general operations reputed company Appeals and Grievances.
• Maintain reputed company of reputed company, providing a culture of teamwork and collaboration.
• reputed company other duties as assigned

Education Required

• Bachelor's Degree in Nursing

Experience Required

• 6 years of clinical acute care experience with at least 3 years of experience with health care grievance and/or appeals issues, preferably in a managed care or reputed company Health Plan environment and/or public services or public benefits programs.
• At least 3 years of management level operations leadership experience.
• Experience working with firm deadlines, regulators, detail oriented with the ability to interpret and apply regulations
• Experience building relationships with organizations and business partners.

Licensure Required

• Registered reputed company (RN) - reputed company, reputed company and unrestricted California License

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