Managed Services - BOS - Appeals & Grievances - Director

Description & SummaryA career in our Managed Services team will provide you an opportunity to collaborate with a wide array of teams to help our clients implement and operate new capabilities, achieve operational efficiencies, and harness the power of technology. Our Compliance Central - Health Pharma Life Sciences Managed Services team will empower you to work across the Pharma Life Sciences value chain, gaining incredible experience in strategy, tech and operations across Commercial, Compliance, Research and Development and Quality functions. We bring a unique combination of industry expertise, technology, data management and managed services experience to create sustained outcomes for our clients and improve business performance. We empower companies to transform their approach to risk and compliance while building your skills in exciting new directions. Have a voice at our table to help design, build and operate the next generation of software and services that manage interactions across the life sciences value chain.To really stand out and make us fit for the future in a constantly changing world, each and every one of us at PwC needs to be a purpose-led and values-driven leader at every level. To help us achieve this we have the PwC Professional; our global leadership development framework. It gives us a single set of expectations across our lines, geographies and career paths, and provides transparency on the skills we need as individuals to be successful and progress in our careers, now and in the future.As a Director, you'll work as part of a team of problem solvers, helping to solve complex business issues from strategy to execution. PwC Professional skills and responsibilities for this management level include but are not limited to:Support team to disrupt, improve and evolve ways of working when necessary.Arrange and sponsor appropriate assignments and experiences to help people realise their potential and support their long-term aspirations.Identify gaps in the market and spot opportunities to create value propositions.Look for opportunities to scale efficiencies and new ways of working across multiple projects and environments.Create an environment where people and technology thrive together to accomplish more than they could apart.I promote and encourage others to value difference when working in diverse teams.Drive and take ownership for developing connections that help deliver what is best for our people and stakeholders.Influence and facilitate the creation of long-term relationships which add value to the firm.Uphold the firm's code of ethics and business conduct.JOB DESCRIPTIONTo really stand out and make us fit for the future in a constantly changing world, each and every one of us at PwC needs to be a purpose-led and values-driven leader at every level. To help us achieve this we have the PwC Professional; our global leadership development framework. It gives us a single set of expectations across our lines, geographies and career paths, and provides transparency on the skills we need as individuals to be successful and progress in our careers, now and in the future.As an AGMS Director, you'll work as part of a team of problem solvers, helping to resolve complex business issues from strategy to execution. PwC Professional skills and responsibilities for this management level include but are not limited to:● Use feedback and reflection to develop self awareness, personal strengths and address development areas.● Delegate to others to provide stretch opportunities, coaching them to deliver results.● Demonstrate critical thinking and the ability to bring order to unstructured problems.● Use a broad range of tools and techniques to extract insights from current industry or sector trends.● Review your work and that of others for quality, accuracy and relevance.● Know how and when to use tools available for a given situation and can explain the reasons for this choice.● Seek and embrace opportunities which give exposure to different situations, environments and perspectives.● Use straightforward communication, in a structured way, when influencing and connecting with others.JOB OVERVIEWThe Director role is a leadership position that brings in-depth appeals and grievances process and regulatory knowledge, critical thinking and leadership to create distinctive value for AGMS and its clients while creating a culture of individual ownership and accountability for high performance. The Director is responsible for leading, organizing and directing the daily activities of the appeals and grievances unit that is responsible for reviewing and resolving member and provider appeals, grievances, complaints and disputes, and communicating resolution to members, providers and authorized representatives in accordance with client policies, processes and regulatory guidance established by the Centers for Medicare and Medicaid. Leads aspects of running an efficient team, including supervising, coaching, training, disciplining, and motivating direct-reports. All tasks related to this position are to be done in a manner consistent with AGMS policies, procedures, quality standards, customer needs and applicable local, state and federal regulations.Years of Experience● Minimum Years of Experience: 3-4 years leadership experience in managed care health plan in experience with member appeals, member complaints, provider payment appeals, provider payment disputes, customer service, utilization management, medical management, claims, regulatory affairs / compliance, and 5-7 years in healthcare claims review, customer service and/or member appeals and grievances.Responsibilities:As a Director, you’ll work as part of a team of problem solvers with consulting and industry experience, helping our clients solve their complex member, provider and business issues.Specific responsibilities include, but are not limited to:● Create a best in class appeals and grievances team that is efficient and effective in managing member and provider appeals and grievances, and works cross functionally and collaboratively with key internal partners to deliver a high functioning, results oriented environment and organization.● Maintain a team of top talent, providing a culture of teamwork and collaboration.● Leads the handling of member and provider appeals and grievances, including providing subject matter guidance and quality assurance reviews of cases.● Responsible for timely daily operations in the A&G team.● Provides director oversight of the management team and staff, including, but not limited to: monitoring of day to day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others.● Establishes and oversees processes and all relevant member and provider correspondence for accuracy, clarity, and cultural appropriateness and sensitivity.● Reviews and analyzes collective grievance and appeals data along with audit results on unit's performance; analyzes and interprets trends and prepares reports that identify root causes of member / provider dissatisfaction; recommends and implements process improvements to achieve member / provider satisfaction or operational effectiveness/efficiencies.● Work collaboratively with cross-functional departments to appropriately address and resolve member and provider appeals and grievances.● Ensures timely appeal and grievance reporting to regulatory agencies, internal Compliance Department, internal Oversight Committees, etc.● Collaborates with cross-functional departments to ensure the use of appropriate appeal and grievance issue codes, timely resolution, and refers to vendor partners as appropriate.● Develop and maintain inventory reports for the appeals process ensuring appropriate productivity, compliance, and inventory management.● Lead, participate and provide representation of the A&G Team at Internal and External meetings/ workgroups and acts as a point person for A&G Programs.● Develop and execute on strategic opportunities to improve the overall appeals & grievance process.● Provide input into the development of automation to guide the team to process efficiencies for all lines of business while maintaining compliance and manageable workloads for staff.● Oversee the routine maintenance and updates of appeal and grievance policies and procedures, member correspondence, etc., consistent with regulatory changes.● Develop and implement short and long-term strategies to improve team results, reducing administrative expenses.● Perform other duties as assigned.Required Knowledge and Skills• Operational managed care experience (customer service, appeals or claims environment) in a leadership capacity.• Operational appeals and grievances experience in a managed care setting, preferably Medicare or Medicaid.• Strong verbal and written communication skills, including letter writing experience.o Language skills:§ Excellent English skills with the ability to read, comprehend, write and communicate verbally with stakeholders & customers.§ Proficiency in Spanish as a first or second language would be preferred.• Experience working with firm deadlines, regulators, detail oriented with the ability to interpret and apply regulations.• Experience building relationships with organizations and business partners.• Ability to multi-task, set priorities and pay attention to details.• Ability to successfully interact with members, medical professionals, health plan and government representatives.• Knowledge of operational managed care terminology. ICD-10 and CPT codes a plus• Proficiency with Microsoft Word, Excel, and PowerPoint.• Excellent organizational, interpersonal and time management skills.• Must be detail-oriented and an enthusiastic team player.• Knowledge of Pega computer system a plus.• Preferred experience with appeals and grievancesDesired Knowledge and Skills• Health claims processing background, including coordination of benefits, subrogation, and eligibility criteria.• Familiarity with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials.Professional and Educational Background• Requires a BA/BS in related field and a minimum of 2 years of Appeals & Grievances managed care experience.• At least 3-4 years of management level operations leadership experience.• Prefer 5-7 years of healthcare, preferably health plan, experience in:o Member appeals, member complaints, provider payment appeals, provider payment disputes, oro Customer service, oro Utilization management, oro Medical management, oro Claims, or regulatory affairs / complianceEducation Degrees/Field of Study required:Degrees/Field of Study preferred:Certifications Required SkillsOptional SkillsDesired Languages Travel RequirementsNot SpecifiedAvailable for Work Visa Sponsorship? NoGovernment Clearance Required? NoJob Posting End Date