Team Lead, Grievance & Appeals

📋 Description

• • Supervise grievance and appeals specialists, providing quality review, performance feedback, disciplinary guidance, and merit/bonus appraisal evaluations.
• • Ensure strict adherence to regulatory, compliance, and HIPAA guidelines for Medicaid, Medicare, and Massachusetts Market operations.
• • Meet all monthly, annual, and semi-annual reporting deadlines related to grievances and appeals.
• • Collaborate with Regulatory Compliance Officers to resolve requests within mandated timelines and maintain accurate tracking for reporting purposes.
• • Monitor Medicaid and Medicare processes to verify full compliance with all applicable regulations.
• • Partner with support departments and compliance officers to ensure company policies and procedures remain current and effective.
• • Establish and maintain an audit process for grievance and appeals operations.
• • Evaluate operational performance and identify process improvement opportunities, analyzing irregular trends to determine root causes and resolution strategies.
• • Manage staffing needs, including recruitment, hiring, and forecasting future team requirements.
• • Review validation reports to confirm accuracy of grievance and appeals documentation.
• • Develop, implement, and monitor workflows to maximize departmental productivity and efficiency.
• • Monitor member-facing departments to ensure timely submission and resolution of grievances and appeals to the Grievance and Appeals Department.
• • Conduct audits and deliver feedback to departments submitting grievances and appeals.
• • Facilitate timely resolution of issues raised by members and providers.
• • Ensure grievance and appeals specialists are available to respond to incoming calls and inquiries.
• • Coordinate and disseminate incoming information to staff to maintain accuracy in internal and external communications.
• • Create, review, revise, and enforce company and departmental policies and procedures.
• • Serve as the primary contact point for CareSource on operational matters with all regulatory bodies across existing and future lines of business.
• • Work closely with the IT department to resolve data transmission issues and ensure system functionality.
• • Proactively update management on team performance, ongoing projects, and critical issues.
• • Provide support to the Service Center during periods of high call volume or operational need.
• • Develop, deliver, or coordinate training programs for grievance and appeals processes across relevant departments.
• • Perform additional job-related duties as assigned.