Grievance & Appeals Manager

Position Summary

The Member Services Manager manages the daily operations of a team of representative that provides support and services to members and other associated individuals and groups. In addition, this position manages an escalation team that investigates and processes grievances and appeals to resolutions and benefits, oversees duties involving contractual obligations to heightened/complex Care Coordination cases, and contractual processes involving consequences resulting from member/patient behavioral issues.

Essential Position Functions

• Provides leadership and direction to the Member Services Representatives, Grievance & Appeal Coordinators and Assurance Coordinator.
• Leads continued development and implementation of the Member Services Department training program, including continual updates of the essential procedures, day to day operation, staff productivity and engagement.
• Provides guidance to staff in the review, research and monitoring of complaints, grievances and appeal cases. Assuring timely, comprehensive and appropriate documented resolution is achieved.
• Completes periodic audits to ensure timely, professional and customer-focused responses to complaints, processing of adverse benefit determinations, grievance and appeals, while maintaining compliance with certificates of coverage and OARS.
• Instills quality communications by developing expectations, standard operating procedures and performing periodic audits.
• Maintains thorough and accurate documentation of departmental audits.
• Regular monitoring to ensure tracking and reporting is performed per Insurance/Provider agreements, Service Level Agreements are met, OARS are followed in our scope of work and adheres to other regulatory requirements .
• Ensures thorough and timely preparation of reports and submissions for all plans.
• Addresses both internal/external customer needs and concern related activities. Ensures programs support toward overall quality improvement, assurance to meet regulatory compliance and adherence to the company standards.
• Working across all departments and the dental practice to achieve full grievance and appeal resolutions.
• Manages challenging and or complex grievances and appeals that require escalation and continued evaluation.
• Establishes and maintains effective communication with reports through regular staff meetings to share information.
• Responsible for the hiring, coaching, mentoring and performance evaluation of the Member Services team.

Education & Experience

Bachelor’s degree and 5 years progressive professional experience performing work related to customer service, preferably in healthcare and at least 2 years' experience managing a diverse team OR an equivalent combination of education and/or experience which will provide the ability to perform the essential functions of the position. A demonstrated background in significant leadership roles with a history of setting and achieving “stretch” goals is preferred.

Compensation

The actual base pay offered to the successful candidate will be based on multiple factors, including but not limited to education, job-related knowledge/skills, experience, geographical location, and internal equity.  

This position is also eligible for incentive pay in accordance with the terms of the Company’s plan.

Company Benefits

Willamette Dental offers the following benefits for this position, subject to applicable eligibility requirements: medical, dental and vision insurance, tuition reimbursement, flexible spending accounts, 401(k) retirement plan with 5% match, accidental death and dismemberment insurance, life insurance, voluntary disability insurance, commuter benefits, two complimentary pairs of Fig scrubs (clinical roles), and employee assistance program.

Paid Time Off (PTO): Eligible employees will accrue a minimum of 120 PTO hours per employment year in addition to seven paid holidays annually. The Company’s PTO program combines vacation and sick leave, which is more generous than Washington State’s Sick Leave Law. Employees in part-time roles working less than 40 hours per week will accrue PTO on a pro-rated basis.

Physical Requirements

The work is primarily performed while sitting and/or standing, but will require occasional walking, bending, stooping and carrying light items such as papers, books, or other supplies. The incumbent uses a computer and other standard office equipment to complete tasks.

Willamette Dental is an equal opportunity employer.

We provide equal employment opportunities to all employees and applicants for employment without regard to an individual’s race (including physical characteristics historically associated with race), religion, color, age, sex (including pregnancy), national origin, veteran status, disability, marital status, genetic information, sexual orientation, gender identity, pregnancy-related condition, or any other classification protected by applicable federal, state or local laws.

This job description is not meant to be an all-inclusive list of duties and responsibilities, but constitutes a general definition of the position’s scope and function in the company.

This position may be exposed to PHI in the course of his/her duties, and will handle protected information (PHI) in a manner consistent with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).