Job Description

Job Title: Senior Manager, Complaints and Grievances
Job ID: 81822870
Status: Full-Time
Regular/Temporary: Regular
Hours:
Shift: Day Job
Facility: UPMC Health Plan
Department: Complaints & Grievances
Location: 600 Grant St, Pittsburgh PA 15219

Description

 UPMC Health Plan is hiring a full-time Senior Manager to help support the Complaints and Grievances Department for its downtown Pittsburgh location at the US Steel Tower. This is a Monday through Friday daylight position.


The successful candidate will strategically implement and manage all aspects of UPMC Health Plan's Member complaints, grievances and appeals processes. Manages all aspects of Provider appeals. Ensures all regulatory requirements are met at all times, regarding complaint/grievance/ appeal timeliness, completeness and accuracy. Ensures all regulations are implemented and staff is trained, efficient and knowledgeable regarding requirements. Meets all NCQA standards. Supports all external and internal audits of the processes. Leadership role in improving trends and compliance.

Responsibilities:

  • Ensure staff are trained on current regulations and are proficient in managing cases accordingly
  • Coordinate preparation and presentation of internal and external audits.
  • Management of provider appeal processes, including managing volume, efficiencies, and improvement recommendations.
  • Oversight of all departments Policies, Procedures, Processes to ensure compliance with all regulatory requirements.
  • Key liaison for Complaint and Grievance Department to the DOH, CMS, DPW, NCQA and internal and external auditors.
  • Oversight of complaint/grievance/appeal tracking tool ensuring it is meeting the needs of the department-this may involve a vendor relationship.
  • Support implementation of appeals tracking system
  • Coordinate functions and trends closely with Coding department, Fraud and Abuse, Claims and Quality Improvement departments for continued improvement opportunities
  • Coordinate with Network department for provider related trends and improvement opportunities regarding member complaint trends and provider appeal facts.
  • Responsible for developing and implementing standardized internal and external reporting structure and methodology; including daily monitoring reports for all products, monthly aggregate reports and trend and improvement opportunity reports
  • Coordinate with Medical Director leadership on improvement opportunities, supplying trend reports and recommendations
  • Responsible for compliance with all regulatory requirements for Member complaints/grievances /appeals daily.
  • Responsible for management of staff ensuring completing member cases timely and accurately.

Qualifications

  • A bachelor's degree in health care management, or related field required; master's degree preferred(extensive related experience will be considered)
  • Minimum of five years of experience in process oriented operations, or project oriented management.
  • Managed care experience is highly preferred
  • Prior experience with Health Insurance Medical claims is preferred
  • Experience with interacting with providers in a managed care environment
  • Management experience with varying levels of staff
  • Experience with report generation, trending and improvement planning
  • Experience with management of a fast paced, multi-faceted environment
  • Excellent presentation skills, experience in leading management level meetings
  • Strong project management skills required, as well as managing all tasks required to meet departmental and company business needs
  • Proficiency in Microsoft Office, including Word, Power Point and Excel

    Licensure, Certifications, and Clearances:

    UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities

Salary Range: $34.96 to $59.20 / hour

Union Position: No

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