Manager- Appeals and Grievances (Remote )

We’ve made a lot of progress since opening the doors in 1942, but one thing has never changed – our commitment to serve, heal, lead, educate, and innovate. We believe that every award earned, every record broken and every patient helped is because of the dedicated employees who fill our hallways.

At Ochsner, whether you work with patients every day or support those who do, you are making a difference and that matters. Come make a difference at Ochsner Health and discover your future today!

This job manages the day-to-day operations of the Appeals and Grievance department. Ensures service standards, adherence to regulatory requirements, and establish policies and procedures regarding the appeals and grievance processes.

This job description is a summary of the primary duties and responsibilities of the job and position. It is not intended to be a comprehensive or all-inclusive listing of duties and responsibilities. Contents are subject to change at the company’s discretion.

Education

Required – Highschool diploma/equivalent.

Preferred – Bachelor’s degree.

Work Experience

Required – 5 years of health care management experience;

OR

4 years of healthcare management experience with a bachelor’s degree.

Preferred – 5 years of healthcare management experience in Medicare Advantage appeals and grievances, utilization management, quality management or member services.

Knowledge Skills and Abilities (KSAs)

Proficiency in using computers, software, and web-based applications.

Effective verbal and written communication skills and the ability to present information clearly and professionally.

Strong leadership, interpersonal, coaching, and conflict resolution skills.

Investigative/analytical skills.

Job Duties

Manages receipt, investigation, and processing associated with member/provider appeals and grievance; ensures appeals and grievances are resolved within regulatory timeframes; and oversees delegated entities for appeals.

Serves as mentor to unit and other departments for complex issues and interpretation of regulatory standards.

Manages, develops, and maintains an effective appeals and grievance process and system consistent with the company policy and stated goals, including, but not limited to mechanisms to monitor appeals and grievances.

Develops tracking mechanisms to document cases and create CMS required reporting.

Ensures timely and effective data collection, coordinates with TMG and EQ Health in providing appeals and grievances data to appropriate parties.

Identifies and analyzes trends and makes recommendations for improvement.

Assists in the development of policies and procedures for all appeals and grievance activities and member/provider processes.

Participates in all internal and external audits related to appeals and grievance and performs internal audits of appeals and grievance process.

Serves as the company’s primary point of contact and subject matter expert related to appeals and grievances and represents the appeals and grievance department at various meetings as applicable.

Hires, trains, coaches, counsels, develops, and evaluates performance of direct reports and creates and implements staff and department performance goals.

Performs other related duties as assigned.

The employer is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, or disability status.

Physical and Environmental Demands

The physical essential functions of this job include (but are not limited to) the following: Frequently exerting 10 to 20 pounds of force to move objects; occasionally exerting up to 100 pounds of force. Physical demand requirements are in excess of those for sedentary work. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Are you ready to make a difference? Apply Today!

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