Manager, Health Plan Business Operations – Grievances and Appeals

Role Overview

• Managing health plan operations and regulatory compliance with emphasis on grievances and appeals.
• Overseeing review, investigation, documentation, processing, negotiating and resolving disputed medical insurance claims per federal and state regulatory requirements.
• Facilitating and participating in internal monitoring for compliance and regulatory audits.
• Providing oversight for administrative functions and management of the department, including personnel and financial management.
• Analyzing and evaluating service for quality improvement including productivity, strategic planning, budget management, and development of performance standards.
• Supervising staff training and managing productivity to ensure effective and balanced case workload.
• Building and managing effective partnerships that engage stakeholders in understanding the issues, identifying opportunities and assisting with resolution.
• Ensuring that department's milestones/goals are met and adhering to approved budgets.

Requirements

• Associate's Degree from an accredited school in business, healthcare or related field required OR Bachelor's degree from an accredited school in business, healthcare or related field preferred
• 4-6 years previous grievance and appeals experience including various lines of business including Medicare, Medicaid, CHP and Exchange preferred
• OR 4-6 years health plan operations including project and/or professional management in areas such as billing/finance regulations, planning & development, setting operational objectives, human resource management and business forecasting required
• AND 1-3 years health insurance claims processing and/or cross functional health insurance experience such as experience involving claims, enrollment, utilization management and/or finance preferred
• Health insurance claims processing knowledge
• specifically QNXT experience valued
• Requires strong organizational skills to set priorities and ability to work with high degree of accuracy and attention to details while responding to tight deadlines and multiple priorities and demands.
• Able to lead, manage, advise, mentor, direct and evaluate employees with grace, fairness and accountability.
• Values and attributes that show empathy, display resilience and show sound judgement in claims management.
• Build and manage effective partnerships that engage stakeholders in understanding the issues, identifying innovative solutions and in supporting best practice claim management outcomes.
• Highly skilled in budget preparation/financial analysis, decision making regarding appropriateness of care review, assist with research design planning, and analyzing and generating quality improvement reports.
• Ability to work independently as well as collaboratively with other internal and external team members to ensure timelines are met.
• Knowledge of personnel management, management of budgets, strategic planning involving collaboration with outside agencies or business entities.
• Ability to communicate and maintain effective working relationships with subordinates, medical staff, administration, and other departments.
• Knowledge and problem-solving process.
• Extraordinary emotional intelligence and quotient, professional communications, interpersonal skills and ability to build genuine trust relationships throughout the organization and beyond.

Benefits

• Outstanding benefits including up to 27 paid days off per year
• Immediate retirement plan employer contribution up to 9.5%
• Generous medical plans
• Free RTD EcoPass (public transportation)
• On-site employee fitness center and wellness classes
• Childcare discount programs & exclusive perks on large brands, travel, and more
• Tuition reimbursement & assistance
• Education & development opportunities including career pathways and coaching
• Professional clinical advancement program & shared governance
• Public Service Loan Forgiveness (PSLF) eligible employer+ free student loan coaching and assistance navigating the PSLF program
• National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer