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Supervisor of Appeals and Grievances


- Fulltime  

Job description

Pay up to $70k DOE.

 

Our client is a premier healthcare facility in Charlotte, N.C.



The Appeals and Grievance Supervisor is responsible for providing clinical and operational oversight of the Appeals, Grievance, and Incident reporting day to day functions. This position is key to promoting integrated care and providing clinical consultation.  The responsibilities of this role include but are not limited to: oversight and management of internal and external compliance with applicable best practice, provider contracts and federal/state rules and regulations.

 

Essential Functions:

 

The Appeals and Grievance Supervisor is responsible for (though not limited to):

·       Manage and provide clinical oversight of the appeals, grievance and incident reporting functions.

·       Provides direct supervision and support of appeals, grievance, and incident staff to include the hiring, training, and supervision of staff.

·       Maintains current knowledge of rules and regulations and is responsible for implementation oversight of regulatory and contractual appeals, grievance, and incident reporting activities.

·       Manages a caseload while providing supervision and consultation to staff and serving as a clinical integrated care resource.

·     Assist with the development and implementation of inter-rater and peer review activities.

·       Assist with the development of innovative strategies to address clinical gaps.

·       Works with the Quality Assurance Manager to develop staff development and training plans.

·       Coordinates investigation and resolution of grievance, appeal and incident reports and collects and analyzes supporting documentation to assess the appropriate determination.

·       Works closely with Medical Services to develop integrated care review process.

·       Prepares cases for Medical Director/or designee review as needed.

·       Develops timely and professional documentation and correspondence that ensures accuracy, completeness and conformance to quality and regulatory standards.

·       Formulates determination language that resolves member or provider issues in a manner consistent with regulatory and accrediting agency requirements.

·       Identifies and solves for potential quality of care trends/concerns.

·       Conducts focused and/or specialized reviews as needed.

·       Provide QM representation and or lead Cross Functional committees as assigned.

·       Attend State meetings as needed to stay informed of changes in clinical best practices, performance metrics, local, State, Federal and Division requirements.

·       Performs other duties as assigned.

 

Qualifications:

 

  • Must be knowledgeable about the rules and regulations that guide the services provided.
  • Must possess strong knowledge of integrated care and the treatment/service needs of the persons served.
  • Must possess strong leadership skills and be able to be effective in getting task done while working through other people.
  • Must have a high level of diplomacy and discretion to effectively negotiate and resolve issues with minimal assistance
  • Ability to effectively present information and respond to questions from internal and external stakeholders.
  • Must be self-motivated and able to work with a wide variety of individuals and possess the ability to negotiate effectively in working with teams, providers and other departments to address concern.
  • Must be an effective trainer and have highly effective communication skills.
  • Detail oriented, able to independently organize and manage multiple tasks.
  • Demonstrate proficiency in Microsoft Office products (such as Word, Excel, Outlook, etc.) and be able to quickly learn new software tools.

 

Education and Work Experience:



Education: A Master of Science in nursing (MSN) is preferred. Bachelor’s or Associate’s Nursing Degree (BSN, ADN) and current North Carolina RN License required. Also requires two years post-licensure experience in a behavioral health setting.

Experience:

·       Experience in quality improvement, analysis, development, public health or related area is preferred.

  • 2+ years of experience in a clinical setting with general nursing exposure in behavioral health is preferred.
  • Management/supervisor experience is required.  
  • Experience with Appeals, Grievance and Incident reporting process is preferred.