Supervisor, Grievance & Appeals

$63,000 - $110,000/Yr

EmblemHealth - 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 other departments, and implement policies to enhance service quality and process improvement.

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, working with applicable business areas to resolve them.
• Review daily/weekly pend reports to ensure proper research is performed and timeframes are met.
• Review quality audits on staff files to evaluate performance and ensure compliance.
• Work with staff to improve performance, monitor attendance and punctuality, complete performance reviews, and conduct weekly staff meetings.
• Manage delegate relationships and collaborate to develop workflows, resolve appeal and grievance issues, and implement quality improvements.
• Create and implement policies and procedures to meet department goals efficiently and cost-effectively.
• Conduct root cause analysis and implement process improvements based on findings, preparing 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
• 1 - 2+ years of managed care experience
• Knowledge of EmblemHealth's programs and department's web-based programs preferred
• In-depth knowledge of grievance and appeal processes, federal/state regulations, and contractual/processing guidelines
• Proficient in MS Office (Word, Excel, PowerPoint, Outlook, Teams)
• Supervisory skills sufficient to direct, motivate, and discipline staff
• Analytical and technical ability to review and analyze procedures and workflow
• Strong communication skills (verbal, written, presentation, interpersonal)
• Ability to organize, prioritize, and effectively manage multiple tasks/projects
• Proven ability to manage a heavy workload in a dynamic, fast-paced environment
• Ability to problem solve, make appropriate decisions, and seek assistance when necessary

Nice-to-haves

• Staff/process management experience preferred
• Additional experience/specialized training may be considered in lieu of educational requirement

Benefits

• Competitive salary range of $63,000-$110,000
• Opportunities for professional development
• Health insurance options
• Retirement savings plan
• Paid time off and holidays