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Years of Experience
Date Last Verified
ProfileSupervisor, Case Resolution Duties: Responsible for overall department timely and effective response and resolution to grievances, complex complaints and appeals that are raised by members and providers relating to all aspects of health plan coverage consistent with contract, regulatory and/or accreditation requirements. Also assists with ensuring compliance with 1) state and federal laws, rules and regulations affecting member rights; 2) contractual obligations as it relates to complaints and appeals; 3) accreditation related requirements. Oversees cases involving highly complex and sensitive member and provider appeals, inquiries and grievances and provides oversight to staff for applying internal policies and procedures, contractual provisions, and regulatory requirements. Oversees diverse and critical member and provider issues that have escalated into complaints and appeals ensuring timely and appropriate responses. Negotiates fees on behalf of members for noncovered or nonparticipating provider services in addition to soliciting claims and other related medical information from providers in order to resolve member inquiries. Reviews and drafts communications for members to assure clear, personal, and accurate communications regarding benefits, programs and other issues which impact members. Interacts with senior management and medical directors to resolve complaints and appeals. Develops and oversees the training for unit staff to ensure workflows and decision-making processes are consistent with corporate goals and guidance. Evaluates/monitors work performance of staff and reports progress, barriers, and solutions. Assists director in overseeing operations of the unit and developing training curriculum to enable staff to solve problems and appropriately resolve cases. Collaborates with other departments to improve processes and workflows across departments. Works with department heads and staff of responsible departments to assure that problem areas are identified in the resolution of appeal cases. Responsible for identifying and elevating to managers any corporate-wide process improvement and resolution of “root” causes to improve the delivery of benefit and payment information, and benefit administration. Participates on various cross departmental committees and other internal meetings to identify, clarify, research, and resolve inquiries and issues. Propose changes to management based on identification and analysis. Presents recommendations to internal committees and executive management, and assists with the implementation of resulting decisions for change/resolution. Assists with oversight of internal investigations, reviews, audits, regulatory inquiries and accreditation related audits. Hires, develops, trains, motivates, and mentors staff to effectively meet corporate standards and department objectives and to ensure that they clearly understand their areas for improvement and have viable developmental plans. Assists in special projects and performs other duties as assigned.
Qualification and Experience
Qualifications: Bachelor’s degree in business administration, communications, statistics, English, or related field, or equivalent combination of education and experience. 5+ years of experience as an analyst, investigator, researcher, paralegal or closely related occupations which demonstrate knowledge of administrative procedures involved in analytical functions and/or assessing and assuring compliance. 1+ year experience as a supervisor or manager. Development/use of business reporting or statistical summary data systems or similar health related business information systems. Experience in handling complex situations requiring problem identification and resolution. 3+ years experience in using PC word processing applications. Ability to work independently, managing multiple priorities simultaneously and under strict time constraints. Strong analytical skills. Strong verbal and written communication skills.