Supervisor, Appeals & Grievances

Alignment Healthcare was founded with a mission to revolutionize health care with a serving heart culture. Through its unique integrated care delivery models, deep physician partnerships and use of proprietary technologies, Alignment is committed to transforming health care one person at a time.

By becoming a part of the Alignment Healthcare team, you will provide members with the quality of care they truly need and deserve. We believe that great work comes from people who are inspired to be their best. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment community.

Position Summary:

Reporting to the AVP of Member Experience, the Supervisor of Appeals & Grievances is responsible for providing oversight of the day-to-day operations of the Grievance and Appeals Department to achieve regulatory compliance with the Centers for Medicare and Medicaid (CMS) and other regulatory agencies.

General Duties/Responsibilities (May include but are not limited to):

1.       Possess the knowledge of Medicare Advantage Appeals and Grievance procedures, protocols, health plan benefits, services, and any other necessary information to resolve member complaints.

2.       Monitors and supervises staff performance and behaviors, productivity, and quality standards specific to those systems and requirements that must be in place to serve our enrolled population.

3.       Assumes and maintains responsibility and accountability for the training, performance of the staff, including but not limited to ongoing staff evaluations, coaching, and disciplining as appropriate to ensure that all qualitative and quantitative goals and objectives are met within the department.

4.       Assists with case volume as deemed necessary to ensure compliance with timeliness standards and assists any caller requesting to speak to a supervisor.                  

5.       Assist with Identify training opportunities and potential system and process improvements relating to grievance/appeal data.

6.       Participate in periodic review and update of grievance/appeal policies and procedures to reflect appropriate legal and CMS requirements as well as participate in CMS Audit preparations and regulator meetings/interviews.

7.       Track time through timecard corrections and approvals; monitor schedule adherence and work with management to ensure staff schedules meet capacity and needs of the business.

1. Conduct interviews as assigned by Manager; oversee the onboarding and training process of new hires.
2. Prepare performance reports as requested by management.

10.   Encourages a spirit of cooperation, teamwork, and accountability among all department employees.

Supervisory Responsibilities:

Carries out supervisory responsibilities in accordance with organization policies and applicable laws.  Responsibilities include training of employees; planning, assigning, and monitoring work; assisting in the rewarding and disciplining of assigned employees; addressing complaints and resolving problems as they pertain to all units as necessary.

Minimum Requirements:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed below are representative of the knowledge, skill, and/or ability required.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1.      Minimum Experience:

1. Three to five years of Supervisor, Lead, related experience and/or training; or equivalent combination of education and experience.
1. Education/Licensure:
1. High school diploma or general education degree (GED).
2. Other: 
1. Knowledge of Medicare Managed Care Plans required.
2. Two to three years Appeals and Grievance experience required.
3. Previous Supervisory experience required; or similar supervisory capacity.
4. Bi-lingual (English/Spanish) preferred.
5. Language Skills:  Ability to read and interpret documents such as safety rules, operating and maintenance instructions and procedure manuals.  Ability to write routine reports and correspondence.  Ability to speak effectively before groups of customers or employees of the organization.
6. Mathematical Skills:  Ability to add and subtract two-digit numbers and to multiply and divide with 10’s and 100’s.  Ability to perform these operations using units of American money and weight measurement, volume, and distance.
7. Reasoning Skills:  Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions.  Ability to deal with problems involving a few concrete variables in standardized situations.
8. Computer Skills:  Intermediate knowledge of MS Office
9. Other Skills and Abilities:

                                                               i.      Excellent leadership skills

                                                             ii.      Excellent communication (oral & written) skills.

                                                           iii.      Strong organizational skills.

                                                           iv.      Demonstrated knowledge of CMS Reporting (ODAG, Stars Measures, etc.,)

j.         Previous Supervisory experience required.

k.       Bi-lingual (English/Spanish) preferred.

l.         Strong knowledge of State and Federal regulatory statutes, including Medicaid and Medicare Parts C and D.

1. Work Environment:
1. The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

                                                               i.      The noise level in the work environment is usually moderate.

Essential Physical Functions:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1.       While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or hear.

2.       The employee is frequently required to walk; stand; reach with hands and arms.

3.       The employee is occasionally required to climb or balance and stoop, kneel, crouch, or crawl.

4.       The employee must occasionally lift and/or move up to 20 pounds.

5.       Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

Alignment Healthcare, LLC is proud to practice Equal Employment Opportunity and Affirmative Action. We are looking for diversity in qualified candidates for employment: Minority/Female/Disable/Protected Veteran.

If you require any reasonable accommodation under the Americans with Disabilities Act (ADA) in completing the online application, interviewing, completing any pre-employment testing or otherwise participating in the employee selection process, please contact [email protected].