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Supervisor, Complaints & Grievances

  • Job ID: 385670400
  • Status: Full-Time
  • Regular/Temporary: Regular
  • Hours: 8 am to 4:30 pm
  • Shift: Day Job
  • Facility: UPMC Health Plan
  • Department: Complaints & Grievances
  • Location: 600 Grant St, Pittsburgh PA 15219
  • Union Position: No
  • Salary Range: $25.81 to $44.67 / hour

Description

UPMC Health Plan is hiring a full-time Supervisor to help support the Complaints and Grievances Department based out of its downtown Pittsburgh location at the US Steel Tower. This position will predominately be working from home, Monday through Friday with the occasional on-call shift. 

This role will oversee the daily operations of the provider appeal team in the Complaints and Grievances Department. They will ensure compliance with the National Committee for Quality Assurance, Department of Health, Department of Public Welfare and the Centers for Medicare and Medicaid Services requirements for complaints, grievances and appeals.

Responsibilities:

 

  • As needed, assist with investigations and processing of complaints, grievances and appeals.
  • Review and revise department policies and procedures.
  • Assist manager in the analysis of complaints, grievances and appeals and in the identification of root causes.
  • Review regulations and requirements governing the complaint, grievance and appeal processes to ensure compliance with new or revised requirements.
  • Support implementation of appeals tracking system
  • Based on the outcome of ongoing monitoring, implement changes to promptly address noted non-compliance issues with re-measurement to ensure compliance.
  • Assess needs for staff training and development.
  • Assess staff competencies and areas for growth.
  • Ensure that the cases are assigned and processed according to regulatory and accrediting requirements.
  • Maintain a positive work environment through employee recognition and interaction.
  • Monitor cases for completeness, accuracy and timeliness.
  • Adjust staff schedules to ensure compliance with requirements for complaints, grievances and appeals.
  • Collaborate with other departments or external customers in the identification of opportunities and the development of action plans.
  • Supervise and monitor ongoing performance of team members.
  • Prepare staff performance reviews.
  • When barriers are identified, intercede with other health plan staff members or external customers as needed to ensure compliance with requirements.
  • Continually examine team performance against department standards.
  • Assist in the development of training materials and training for staff.
  • Assist in the preparation for external surveys, audits or reviews of department processes.
  • Monitor the inventory of complaints, grievances and appeals.
  • Participate in interviewing, hiring and training of team members.
  • Monitor and prepare routine reports.
  • Submission of executive complaint resolutions to executive leadership.
  • Provide feedback to staff to assist them in meeting goals.
  • Manage the department in the absence of the manager.
  • Manage special projects.
  • Evaluate the department processes and make recommendations to improve operational performance.

 

Qualifications

  • Bachelor's degree in business, health care, management or a related field, or equivalent relevant experience required.
  • 3 years (or more) of experience in process-oriented operations, or project-oriented management.
  • Experience with MC400 highly preferred. 
  • Claims experience highly preferred.
  • Provider appeals experience highly preferred. 
  • Managed care experience preferred.
  • Supervisory experience preferred
  • High degree of professionalism, enthusiasm and initiative on a daily basis.
  • Ability to work in an environment that has time-sensitive deliverables is a must.
  • Ability to manage multiple tasks and projects, and forge strong interpersonal relationships within the department and with other departments.
  • Attention to detail, strong organizational, communication, planning, analytical and problem-solving skills are critical to the success of this position.
  • Skills with MS Office suite products.
  • Experience with a managed care transactional system preferred.


Licensure, Certifications, and Clearances:

UPMC is an Equal Opportunity Employer/Disability/Veteran

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   Current UPMC employees must apply in HR Direct