IRE Grievance & Appeals Mgr II

IRE Grievance & Appeals Manager II

The Manager II Grievance/Appeals responsible for management oversight of grievances and appeals departmental units to investigate, resolve, and respond to grievances and appeals, manages inventory and production levels, and operational and plan risk, ensures quality, and regulatory compliance. This role specifically oversees the IRE Team.

How you will make an impact:

• Coordinates Grievance and Appeals Committee Meetings.
• Assists grievance and appeals leadership in regulated audits.
• Oversight of the IRE portions of Medicare audits and universe production.
• Serves as a resource for complex issues and interpretation of claims, provider contracts and data, eligibility, member contracts, benefits, clinical decisions, pharmacy on pre-service and post service appeals and grievances related to non-clinical and clinical services, quality of service and quality of care issues including executive and regulatory grievances.
• Oversees and implements new subsystems, procedures, techniques and supports digital automation objectives.
• Analyzes and develops strategies by achieving performance thresholds within budgetary guidelines.
• Monitors trends and analyzes grievance and appeals data to identify and recommend plan and policy changes and to ensure state and federal regulatory compliance and resolution within the regulatory timeframes.
• Ensures programs support overall QI program and meet regulatory compliance and the company standards. Hires, trains, coaches, counsels, and evaluates performance of direct reports.

Minimum qualifications:

• Bachelor's degree and a minimum of 5+ years grievance & appeals experience and a minimum of 3 years of management experience in the healthcare industry; or any combination of education and experience which would provide an equivalent background.
• For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

Preferred Skills, Capabilities and Experiences:

• Three years of leadership or managerial experience is strongly preferred.
• Experience with IRE/Maximus and Medicare compliance, programs, guidelines, and processes are strongly preferred.
• Solid knowledge of Medicare Grievance and Appeals rules and regulations is highly preferred.
• Demonstrated critical thinking and problem-solving abilities are highly preferred.

For candidates working in person or virtually in the below locations, the salary range for this specific position is $82,720 to $148,896:

Locations: District of Columbia, Maryland, New Jersey and New York

In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the company. The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.

Job Level: Manager

Workshift:

Job Family: CLM > Claims Support

Elevance Health is a health company dedicated to improving lives and communities and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.