Grievance and Appeals Quality Assurance Program Manager

Salary Range: $83,243 - $124,864

The expected pay range is based on many factors, such as experience, education, and the market. The range is subject to change.

FLSA Status: Exempt

Department: Grievance and Appeals

Reports To: Director, Grievance and Appeals Operations

General Description Of Position

The Grievance and Appeals Quality Assurance Program Manager is responsible for performing retrospective and concurrent internal quality review of grievances and appeals to ensure they are categorized and processed in accordance with state and federal regulatory requirements and SCFHP policies and procedures as set forth for each line of business, including conducting review and root-cause analysis of grievance and appeal data to identify and report trends to internal and external stakeholders. In addition, the Grievance and Appeals Quality Assurance Associate is responsible for participating in internal audits and for providing input and conducting training for member-facing staff and for special projects related to grievance and appeals activities.

Essential Duties And Responsibilities

To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below.

Conduct frequent retrospective and concurrent quality review of grievances and appeals to ensure they are categorized and processed in accordance with state and federal regulatory requirements and SCFHP policies and procedures as set forth for each line of business.

Develop and maintain up-to-date mechanisms for documenting and storing the results of grievance and appeals quality reviews for evaluation by Grievance and Appeals Management.

Review grievance and appeals notices for all SCFHP lines of business to ensure written communications include concise and accurate information and language that is easy to understand.

Conduct quality assurance checks on operational and regulatory reports to align with report specifications.

Conduct frequent review and root-cause analysis of grievance and appeals data and identify and report trends to applicable internal and external stakeholders.

Provide input for grievance and appeals training and assist in conducting training for member-facing SCFHP and delegated entity staff.

Participate in internal and cross-functional team meetings, committees and workgroups as necessary to understand how the Grievance and Appeals Department supports other departments and stay informed of operational changes that may affect Grievance and Appeals Department operations.

Participate in and/or conduct offsite audits of delegated entities.

During times of high volume work and/or staffing shortages, perform grievance and appeals case processing.

Perform Other Related Duties As Required Or Assigned.

REQUIREMENTS – Required (R) Desired (D)

The requirements listed below are representative of the knowledge, skill, and/or ability required or desired.

Bachelor’s Degree in English Literature, English Composition or equivalent experience, training or coursework. (R)

Ability to conduct internal quality reviews, auditing and/or training. (R)

Knowledge of managed care principles and practices with an emphasis in Grievance and Appeals and/or Claims or Utilization Management. (R)

Knowledge of Medi-Cal and Medicare guidelines and regulations. (R)

Ability to conduct research, root cause analysis and identify trends to accurately identify issues and recommend interventions. (R)

Ability to consistently meet accuracy and timeline requirements to maintain regulatory compliance. (R)

Spanish, Vietnamese, Chinese, or Tagalog language bi-lingual skills. (D)

Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, and external stakeholders over the telephone, in person or in writing and the ability to remain calm and de-escalate tense situations. (R)

Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R)

Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R)

Proficient in adapting to changing situations and efficiently alternating focus between tasks to support the Grievance and Appeals Department operations as dictated by business needs. (R)

Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word, Excel, and Visio or similar applications. (R)

Familiarity with project management software such as Asana, Wrike, Microsoft Project or Monday. (D)

Ability to use a keyboard with moderate speed and a high level of accuracy. (R)

Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R)

Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R)

Ability to maintain confidentiality. (R)

Ability to comply with all SCFHP policies and procedures. (R)

Ability to perform the job safely and with respect to others, to property and to individual safety. (R)

Work weekends and company holidays as needed based on business regulatory requirements. (R)

Maintenance of a valid California driver’s license and acceptable driving record, in order to drive to and from offsite meetings or events; or ability to use other means of transportation to attend offsite meetings or events. (R)

WORKING CONDITIONS

Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications.

Physical Requirements

Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation:

Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R)

Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R)

Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R)

Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R)

Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R)

Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R)

ENVIRONMENTAL CONDITIONS

General office conditions. May be exposed to moderate noise levels.

EOE