Supervisor, Grievance & Appeals

$63,000 - $110,000/Yr

Connecticare - New York, NY

Full-time - Mid Level

New York, NY

Insurance Carriers and Related Activities

About the position

The Supervisor of Grievance & Appeals is responsible for overseeing the daily operations of the Grievance and Appeal Specialists at EmblemHealth. This role ensures compliance with department performance standards and government regulations while continuously improving operational efficiency. The supervisor will monitor staff performance, manage relationships with external delegates, and implement policies to enhance service quality and team morale.

Responsibilities

• Manage the day-to-day operations of the staff including new hires.
• Ensure the appropriate staff responds to all member/provider inquiries within the stipulated time frames, ensuring member/provider satisfaction and compliance.
• Accountable for all performance issues and take appropriate action as warranted, maintaining coverage for expedited appeal files on weekends and holidays.
• Identify and conduct root cause analysis of appeal issues, collaborating with applicable business areas to resolve them.
• Review daily/weekly pend reports to ensure proper research is performed and timeframes are met.
• Conduct quality audits on staff files to evaluate performance and ensure compliance.
• Monitor attendance and punctuality; complete performance reviews; conduct weekly staff meetings to encourage open communication and build team morale.
• Manage delegate relationships (Beacon, HCP, CMO, EviCore, etc.) to develop workflows and resolve appeal and grievance issues.
• Create and implement policies and procedures to meet department goals efficiently and cost-effectively.
• Participate in creating and implementing continuous process and quality improvement initiatives while fostering a high-performing team environment.
• Conduct root cause analysis and implement process improvements based on findings; prepare for internal/external audits.
• Participate in the recruitment of qualified candidates and monitor the training process for new staff members.

Requirements

• Bachelor's Degree
• 4 - 6+ years of relevant, professional work experience required
• 1 - 2+ years of managed care experience required
• Staff/process management experience preferred
• Knowledge of EmblemHealth's programs and web-based programs preferred
• In-depth knowledge of grievance and appeal processes, federal/state regulations, and contractual/processing guidelines required
• Proficient in MS Office (Word, Excel, PowerPoint, Outlook, Teams, etc.) required
• Supervisory skills sufficient to direct, motivate, and discipline staff required
• Analytical and technical ability to review and analyze procedures and workflow and make recommendations for streamlining processes required
• Strong communication skills (verbal, written, presentation, interpersonal) with all types/levels of audience required
• Ability to organize, prioritize, and effectively manage multiple tasks/projects with competing priorities/deadlines required
• Proven ability to manage a heavy workload in a dynamic, fast-paced environment required
• Ability to problem solve, make appropriate decisions, and seek assistance when necessary required

Nice-to-haves

• Additional experience/specialized training may be considered in lieu of educational requirement

Benefits

• Competitive salary range of $63,000-$110,000
• Full-time employee status
• Regular employment with potential for career advancement