About Us:

Santa Clara Family Health Plan (SCFHP) is a local, community-based health plan dedicated to improving the health and well-being of the residents of Santa Clara County. Working in partnership with providers and community organizations, we serve our neighbors through our Medi-Cal and and SCFHP DualConnect (HMO D-SNP) health care plans.

About the role:

The Manager, Grievance & Appeals is the primary point person responsible for the development and management of all grievance and appeal related activities and for providing a positive and professional experience for members and providers going through grievance or appeals processes. As the go-to person for grievances and appeals, this position interprets guidance from regulators, implements processes to ensure compliance, oversees the day-to-day operations of the grievance and appeals staff and represents the plan externally with providers, delegates and regulators in scheduled and ad hoc meetings, joint operating committee meetings, hearings and audits.

Day to Day:

• Read, interpret and implement all regulatory guidance related to the handling of appeals and grievances, including the Medicare Managed Care Manual, State and Federal contracts, APLs, DPLs and other memos that provide direction.
• Demonstrate a solid understanding of the appeals and grievance processes, including all regulatory and reporting requirements.
• Establish and document processes, policies, procedures and workflows to support compliant and timely handling of appeals and grievances.
• Create and implement any necessary corrective action plans to bring areas of non-compliance into compliance.
• Manage all grievance and appeals-related reports ensuring accuracy and timeliness of submissions.
• Prepare case files and represent SCFHP in State Hearings or other escalated types of cases, including development of the Statement of Position and Independent Review Entity (IRE) case narratives.
• Lead and facilitate active participation and guidance from the attendees of the Grievance and Appeals Workgroup.
• Lead efforts to identify grievance and appeal case trends and conduct root cause analysis for the development of interventions to improve SCFHP operations and the customer experience for members and providers.
• Manage internal and external audits of grievances and appeals.
• Direct and manage appeals and grievance staff in order to adhere to accurate processing and resolution of appeals and grievances. This includes demonstrating the flexibility and judgment required to constantly re-shift prioritization of cases to accommodate timely handling and resolution.
• Develop and manage reporting to monitor key performance indicators, identify trends, conduct root cause analysis, report to appropriate committees, and adhere to regulatory reporting requirements.

About You:

• Four-year degree in General Business, Law, Social Sciences or Health Care Administration, or related experience.
• Minimum two years management experience including direct supervisory experience of multiple staff, responsibility for hiring and performance management.
• Minimum three years of health plan operations experience, with demonstrated knowledge of health plan operations and the interactions between appeals and grievances, customer service, utilization management, claims and provider relations.
• Two years of experience working in grievances and/or appeals (including medical and pharmacy), or a closely related area of health plan operations.
• Knowledge of Medicare and Medicaid/Medi-Cal requirements.
• Process/systems thinker with attention to detail and the ability to develop and improve cross-functional processes.

Please review the full job description on our Career’s page: https://phf.tbe.taleo.net/phf04/ats/careers/v2/viewRequisition?org=SANTCLAR2&cws=38&rid=1053

Job Type: Full-time

Pay: $116,695.00 - $180,877.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Tuition reimbursement
• Vision insurance

Schedule:

• Monday to Friday

Ability to commute/relocate:

• San Jose, CA: Reliably commute or planning to relocate before starting work (Preferred)

Application Question(s):

• Do you have a minimum of two years of management experience including direct supervisory experience of multiple staff, responsibility for hiring and performance management?
• Do you have a minimum of three years of health plan operations experience, with demonstrated knowledge of health plan operations and the interactions between appeals and grievances, customer service, utilization management, claims and provider relations?
• Do you have two years of experience working in grievances and/or appeals (including medical and pharmacy), or a closely related area of health plan operations?

Education:

• Bachelor's (Preferred)

Work Location: One location

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