The Grievances Manager is an important part of the leadership team within the Customer Service Department. The Manager oversees the Grievances Program, which is the heartbeat of Plan operations and a direct insight to member experience. The Grievances Manager is accountable for inspiring a diverse team of specialists to investigating member concerns and solving their problems. The Grievances Manager must be committed to finding and resolving issues and improving processes.
- Manages, builds, mentors, and coaches the Grievances team to drive business objectives of improving member experience and meeting regulatory and contractual requirements for timely investigating and responding to member complaints. Drives personal and team accountability for all work related to the Grievances processes.
- Oversees Grievances investigations, providing guidance and direction to the team. Manages all activities related to reporting, management, and continuous improvement of Grievances program.
- Performs root cause analysis to identify potential gaps and develop an action plan to alleviate future issues. Coordinates with peers and other departments within the organization to investigate, resolve, and if appropriate, correct deficiencies.
- Produces regular trending and other reporting on member complaints and share with peers and leadership within the organization to address member concerns and reduce overall Grievances volume.
- Produces and presents monthly Client reporting packages that detail volume, content, and timeliness of grievances.
- Maintains, reviews, and revises (as needed) Grievances policies and procedures. Trains team on policies, procedures, and regulatory requirements.
- Rapidly develops and maintains a thorough and up-to-date understanding of organizational functions and processes, client relationships, and Medicare requirements for all aspects of Health Plan Grievances.
- Communicates and collaborates with internal business partners, clients, and other outside
parties, building strategic partnerships to foster and support effective business relationships to support the program.
- Serves as subject matter expert in all regulatory and client audits and ensure the Grievances team’s audit readiness.
- Collaborates with project implementation teams regarding new clients or systems.
- Supports NCQA accreditation as the business owner for Grievances.
- Escalates issues of an urgent or critical nature to management when necessary, promptly to senior leadership.
- Bachelor’s degree, 1+ year of leadership experience, and 6+ years of relevant experience preferably in healthcare, grievances, insurance, or a related field
- Favorable leadership skills with the ability to manage a team remotely, build a culture of accountability, ownership, and continuous learning, and drive subject matter expertise within the team by utilizing cross-training and team learning activities
- Strong judgment, customer service skills, and personal and professional ethics
- Strong written and verbal communication, problem-solving, interpersonal, logical, analytic, critical thinking, and decision-making skills with the ability to interpret and conceptualize data
- Experienced at building a team including effective hiring of new employees and development of current staff
- Ability to prioritize work in a fast-paced environment with competing priorities
- Must be a dynamic and solution-oriented self-starter who can balance working collaboratively and autonomously as required
- Experience working in a Medicare Advantage and/or working knowledge of Appeals and Grievances or other health plan processes preferred
- While performing the duties of this job, the employee works in normal office working conditions.
Disclaimer: The job description describes the general nature and level of work being performed by people assigned to this job and is not intended to be an exhaustive list of all responsibilities, duties and skills required. The physical activities, demands, and working conditions represent those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job duties and responsibilities.