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GENERAL SUMMARY:

To plan, direct, evaluate and coordinate the activities associated with the Monitoring & Oversight department of Customer Services, as it relates to key HAP initiatives and service excellence. To perform auditing and real-time monitoring of complaints, grievances and, appeals for all product lines (HMO, AHL, Medicare Advantage (MA) and Prescription Drug Plan (PDP) to ensure complete, accurate and timely processing, in accordance with regulatory mandates including NCQA, Department of Labor (DOL) and Center for Medicare/Medicaid Services (CMS). To analyze, maintain and report on all grievance and appeal related information to the Department of Financial Services (DIFS), CMS, Member Services Committee of the HAP Board of Directors, CEO and

COO of HAP and the Vice President of Customer Services. Maintain formal history of grievances and appeals to utilize for process improvements, forecasting and planning for people, resources and technology. To develop and implement an on-going training plan for all resources handling complaints, grievances and appeals and ensure staff is aware of changing regulatory requirements.

PRINCIPLE DUTIES AND RESPONSIBILITIES:

• Provides daily direction, monitoring and oversight for Appeal and Grievance Department, which includes the appropriate coaching and development, planning, staffing and coordination of activities as they pertain to divisional and corporate goals, strategies and objectives.

• Provides daily strategic direction, planning and forecasting for the Appeal and Grievance and Oversight team to ensure departmental, corporate and system initiatives are defined, implemented, tracked, monitored and achieved.

• Determines training, policy, procedure and benefit needs related to timely and accurate processing of all case types.

• Ensures compliance within the individual regulatory mandates for every product line (NCQA, DIFS, DOL, HIPAA and CMS) an operate within HAP defined business processes.

• Supplies necessary internal control oversight information regarding system changes affecting the Appeals & Grievance processing ensuring that proper system testing, system documentation, user training, etc. is performed prior to implementation.

• Develops and reviews department and corporate operational policies and procedures in accordance with DIFS, NCQA, DOL and CMS regulations and within departmental standards. Leads team to ensure workflow is continuous, performance standards are met and staff operates within the regulatory mandates such as CMS, NCQA, DIFS, DOL and HIPAA with respect to the various product lines.

• Partners to collect and submit the corporate grievance and appeal reports for Medicare Part B, C & D that must be electronically sent to CMS for Data Validation.

• Monitors the timely completion of all cases that are submitted through the Medicare Complaint Tracking Module (CTM), DIFS, Pega, and Appeals and Grievances.

• Prepares all appeal and grievance data for regulatory agency reviews (NCQA, CMS, DIFS and Medicare 5 Star). Attends regulatory agency interview meetings during their review of the appeal and grievance data to answer questions and explain monitoring processes to the various interviewers from these agencies.

• Develops, maintains and implements an on-going training plan for the appeals and grievance personnel to provide department-wide or individualized training based on audit results. Develops weekly audit reports to share with management and teams. Provides just-in-time training to staff based on real-time monitoring results.

• Supports achievement of HAP and Department specific KPIs to measure compliance and operational performance. Supports in identifying key areas of process improvement activities to help achieve of HAP’s Medicare 5-Star metric goals as it relates to appeal, grievance and complaints.

• Participates in Medicare Programs workgroups to ensure successful achievement of corporate objectives and regulatory compliance. Participates in Medicare Program conference calls with CMS to ensure changes are understood and communicated effectively to appropriate staff.

• Analyzes complaint, appeal and grievance data to identify impacting trends, perform root cause analyst and recommend customer service and process improvements. Coordinate preparation of annual appeal and grievance report. Presents report to the Member Services Committee of the HAP Board of Directors annually.

• Develops skills and competencies of indirect reports to maximize employee engagement, increase productivity and create an environment of teamwork and commitment; coach and counsel people to exceed performance levels through professionalism, positive relations and timeliness in all customer contacts.

  EDUCATION/EXPERIENCE REQUIRED:

• Bachelor’s degree in Health Care, Business or related field required. Master’s Degree preferred.

• Minimum of four (4) years combined customer service and professional experience in health care, call center, business and/or insurance environment or capacity required.

• Minimum of four (4) years of experience with Appeals and Grievances and demonstrated knowledge of HMO and PPO products and CMS regulations and

  guidelines for Medicare products required.

• Minimum of two (2) years of project coordination or project management and data analysis, validation and reporting required.

• Minimum of one (1) year of CMS Plan or Data Validation Audit experience; NCQA site visit experience preferred.

  CERTIFICATIONS/LICENSURES REQUIRED:

• Certified in Health Care Compliance preferred.

  SKILLS AND ABILITIES:

• Proven managerial skills which include ability to lead teams effectively through a coaching methodology.

• Strong organizational and communication skills, both verbal and written and the ability to express ideas logically, cogently and persuasively.

• Ability to develop and implement recommendations and strategies, make independent judgments and effectively manage multiple responsibilities within

  multiple distinct operations.

• Excellent analytical and decision-making skills.

• Ability to comprehend and suggest modification to technical computerized systems or other applications as they relate to call center operations.

• Skills to learn in detail the HAP policies, procedures and benefits.

• Skills to develop a good understanding of the health care system and the HAP provider network.

• Thorough understanding of the HMO and Medicare Managed Care delivery systems.

• Extensive knowledge of State, DOL, NCQA and CMS guidelines as related to grievances/appeals and Medicare program regulations.

• Strong human relations skills.

• Technical understanding of database oriented systems.

• Proficient with Word, Excel and/or Access.

• Basic understanding of accounting principles.

Additional Information

• Organization: HAP (Health Alliance Plan)

• Department: Appeals and Grievances

• Henry Ford Health Location: HAP (Health Alliance Plan)

• Shift: Day Job

• Union Code: Not Applicable

  Additional Details

  This posting represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and functions. It should be understood, therefore, that incumbents may be asked to perform job-related duties beyond those explicitly described above.

Overview

Henry Ford Health partners with millions of people on their health journey, across Michigan and around the world. We offer a full continuum of services – from primary and preventative care to complex and specialty care, health insurance, a full suite of home health offerings, virtual care, pharmacy, eye care and other health care retail. With former Ascension southeast Michigan and Flint region locations now part of our team, Henry Ford’s care is available in 13 hospitals and hundreds of ambulatory care locations. Based in Detroit, Henry Ford is one of the nation’s most respected academic medical centers and is leading the Future of Health: Detroit, a $3 billion investment anchored by a reimagined Henry Ford academic healthcare campus. Learn more at henryford.com/careers .

Benefits

The health and overall well-being of our team members is our priority. That’s why we offer support in the various components of our team’s well-being: physical, emotional, social, financial and spiritual. Our Total Rewards program includes competitive health plan options, with three consumer-driven health plans (CDHPs), a PPO plan and an HMO plan. Our team members enjoy a number of additional benefits, ranging from dental and eye care coverage to tuition assistance, family forming benefits, discounts to dozens of businesses and more. Employees classified as contingent status are not eligible for benefits.

Equal Employment Opportunity/Affirmative Action Employer

Equal Employment Opportunity / Affirmative Action Employer Henry Ford Health is committed to the hiring, advancement and fair treatment of all individuals without regard to race, color, creed, religion, age, sex, national origin, disability, veteran status, size, height, weight, marital status, family status, gender identity, sexual orientation, and genetic information, or any other protected status in accordance with applicable federal and state laws.