Grievances & Appeals Manager

COMPANY OVERVIEW

Zing Health is a tech-enabled insurance company making Medicare Advantage the best it can be for those 65-and-over. Zing Health has a community-based approach that recognizes the importance of the social determinants of health in keeping individuals and communities healthy. Zing Health aims to return the physician and the member to the center of the health care equation. Members receive individualized assistance to make their transition to Zing Health as easy as possible. Zing Health offers members the ability to personalize their plans, access to facilities designed to help them better meet their healthcare needs and a dedicated care team. For more information on Zing Health, visit www.myzinghealth.com.

SUMMARY DESCRIPTION:

The Grievances & Appeals Manager will be responsible for ensuring that responses to complaints, grievances and appeals is done in a timely, professional, customer-focused manner, and is well-documented. Ensures that tracking and reporting is performed per CMS, and other regulatory requirements and Zing business standards. Maintains and coordinates staff activities to achieve departmental and corporate goals to improve service to customers/providers and assures regulatory compliance. Addresses both internal/external customer/provider needs, and concerns related to team activities. Ensures programs support overall Quality Improvement Programs and meet regulatory compliance and the company standards. Hires, trains, coaches, counsels, evaluates performance of direct reports, and other duties as assigned.

ESSENTIAL FUNCTIONS:

Develops and maintains program description, departmental workflows, working documents and tools, Service Level Agreements, Policies and Procedures, reports, trainings, and other work product as needed.
Communicates program status to Vice President, Clinical Operations and other Executives as needed
Reports to internal and external QI meetings; works with regulatory agencies to secure approvals as needed.
Prepares all Grievance & Appeals reports, as required by CMS or other regulatory agencies per format and timeframes specified. Report drafts are prepared in advance with sufficient time for internal management review.
Provides leadership and direction to staff in the G&A department.
Hires, trains, coaches, counsels, and evaluates performance of direct reports.
Leads continued development and implementation of an organizational grievance training program – regular training of departments and individual staff as required to assist in ensuring regulatory compliance.
Assists with the implementation and use of AG360, the G&A tracking and monitoring tool.
Partners with departmental leaders to identify trends and improve operational processes that impact member and provider experience with the health plan and the provider network.

Provides guidance to Grievances & Appeals staff in the review, research, monitoring and routing of complaints, grievances and appeal cases to appropriate personnel to assure timely, comprehensive and documented resolution is achieved. Works across departments to achieve full grievance and appeal resolutions.
Manages challenging and/or complex grievances and appeals that require escalation and continued evaluation.
Supports Zing Compliance Department in resolution of Compliance Tracking Module (CTM) Complaints.
When necessary, reviews, researches and directs complaints, grievances and appeal cases to appropriate personnel, and follows up to ensure that resolution has occurred, documentation is complete, required timeframes are met, and proper written communication of the decision has occurred. In most cases, prepares the written communication of the decision in plain written language. Coordinates additional follow up activities with appropriate department managers and/or leads and tracks to conclusion.
Maintains grievance and appeal tracking in a timely manner for all lines of business. This includes logging incoming grievance, tracking dispositions and maintaining timeliness of resolution as required by state and federal mandates.
Maintains electronic files of all documentation, and appropriate follow up documentation in AG360 system.
Ensures that all information to providers, members, employees, and other appropriate persons is accurate, consistent and customer sensitive.
When needed for specific types of grievances or appeals, prepares summaries for committee review, documents meeting discussions, and communicates decision in writing.
Participates in internal committee and interdisciplinary meetings, reporting recent activity and analysis of trends, and makes recommendations for problem resolution and performance improvement
Conducts and documents internal audits of the G&A department as required by CMS, or other regulatory agencies per format and timeframes specified.
Ensures G&A department compliance with CMS, or other regulatory agencies and Zing business standards.
Responsible to maintain Zing’s confidential information in accordance with Zing policies, and state and federal laws, rules and regulations regarding confidentiality. Employees have access to Zing data based on the data classification assigned to this job title
Follows standard protocols, processes, and policies.
Performs other duties, projects and actions as assigned.

QUALIFICATIONS AND REQUIREMENTS:

JOB REQUIREMENTS:

Bachelor of Science/Business Administration Degree in a related field preferred
3-5 years of mid-level management experience in the health care industry
Minimum 2 years’ experience in Grievance and Appeals in a Managed Care Plan; or any combination of education and experience, which would provide an equivalent background
Outstanding inventory management skills
Excellent oral, written and interpersonal communication skills, financial and business acumen, problem-solving skills, facilitation, and analytical skills
Ability to ensure organizational compliance with all required rules, policies, and procedures.
Proficient knowledge of Microsoft Office tools
Achieves results, builds trust, communicates effectively, customer and quality focused
Ability to multi-task, adapt to changing priorities, manage a diversity of high priority projects in a fast-paced environment
Ability to organize and coordinate information with multiple departments and different staff levels, including management
Strong problem solving and customer service skills
Self-Starter and takes Self-Initiative
Experience with utilizing multiple data bases
Experience in and Engages in Process Improvement
PC proficiency to include Word, Excel, PowerPoint, database experience and Web based applications

PREFERED SKILLS

Experience in conducting training
Knowledge of Medicare, CMS, Claims Processing, EOCs
Bilingual – English and Spanish
Personal management skills — Plan and manage multiple assignments and tasks, set priorities, and adapt to changing conditions and work assignments
Teamwork —ability to work well with one or more groups
Interpersonal effectiveness — Relate to co-workers and build relationships with others in the organization
Strong work values — Dependability, honesty and a positive attitude