Manager, Appeals & Grievances

Manager, Appeals & Grievances

Manager I - BPM

Who We Are:

UST HealthProof is a trusted partner for health plans, offering an integrated ecosystem for health plan operations. Our BPaaS solutions manage complex admin tasks, allowing our customers to prioritize members' well-being. With our commitment to simplicity, honesty, and leadership, we navigate challenges with our customers to achieve affordable health care for all.

We have a strong global presence and a dedicated workforce of over 4000 people spread across the world.

Our brand is built on the strong foundation of simplicity, integrity, people-centricity, and leadership. We stay inspired in our goal to unburden healthcare and ensure it reaches all, equitably and effectively.

You Are:

The Manager, Appeals & Grievances, is accountable for processing and reporting all Grievances and Appeals to the highest quality possible and for ensuring that Grievances and Appeals are resolved timely and within all regulatory frameworks.

The Opportunity:

* Develops and implements effective strategies that enables the department to maintain efficient and cost-effective processes.

* Establishes operational vision and obtains approval from senior management relative to quality and audit operations including Grievances and Appeals.

* Establishes and maintains Grievance and Appeals processes and systems to ensure data quality to support quality, production, and financial goals.

* Drives operational excellence into all processes and departmental interactions based on CMS and HealthProof requirements.

* Leads employees and other management in developing effective intercompany workflows for the Grievance and Appeals processes and all quality and audit functions.

* Leads, coaches, develops, and implements training programs to ensure staff competence.

This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.

What You Need:

* EDUCATION:

* Bachelor's degree in related field. Continuous learning, as defined by the Company s learning philosophy, is required.

* EXPERIENCE:

* Five years of experience of progressive responsibility in a Health

* Plan Appeals & Grievances operations or quality including grievance and

* Health Plan is required.

* SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:

* Ability to work with Senior Management in creating an operating plan for the Grievance and Appeals Department.

* Proven critical thinking skills and ability to translate knowledge to corporate departments.

* Knowledge of the Grievance and Appeals regulations per CMS.

* Ability to create actionable plans through use of data analysis.

* Demonstrated history of generating results and having an impact on organizations.

* Demonstrated forward thinking in areas of technology support, process improvement, and leadership.

* Ability to establish training programs and motivate employees in a quality minded environment.

* Strong leadership skills with the ability to mentor staff and develop teams.

* Articulate and be persuasive in presenting business-case for change-management.

* Must demonstrate leadership ability and team building skills to effectively supervise professional and non-professional staff and interact with all levels of management.

* Ability to work with and empower others on a collaborative basis to ensure success of unit team.

* Ability to effectively exchange information at the appropriate level, in verbal or written form, by sharing ideas, reporting facts and other information, responding to questions, and employing active listening techniques.

* Ability to effectively present budgetary and/or cost information and respond to questions as appropriate.

* Ability to establish workflows, manage multiple projects, and meet necessary deadlines.

Compensation can differ depending on factors including but not limited to the specific office location, role, skill set, education, and level of experience. UST HealthProof provides a reasonable range of compensation for roles that may be hired in various U.S. markets as set forth below.

Role Location: Remote

Compensation Range: $80,000-$100,000

Benefits

Full-time, regular employees accrue up to 16 days of paid vacation per year, receive 6 days of paid sick leave each year (pro-rated for new hires throughout the year), 10 paid holidays, and are eligible for paid bereavement leave. They are eligible to participate in the Company's 401(k) Retirement Plan with employer matching. They and their dependents residing in the US are eligible for medical, dental, and vision insurance, as well as the following Company-paid benefits: basic life insurance, accidental death and disability insurance, and short- and long-term disability benefits. Regular employees may purchase additional voluntary short-term disability benefits, and participate in a Health Savings Account (HSA) as well as a Flexible Spending Account (FSA) for healthcare, dependent child care, and/or commuting expenses. Certain regular employees may have the potential for quarterly incentive-based bonuses and or commissions depending on role. Benefits offerings vary in Puerto Rico.

Part-time employees receive 6 days of paid sick leave each year (pro-rated for new hires throughout the year) and are eligible to participate in the Company's 401(k) Retirement Plan with employer matching.

Full-time temporary employees receive 6 days of paid sick leave each year (pro-rated for new hires throughout the year) and are eligible to participate in the Company's 401(k) program with employer matching. They and their dependents residing in the US are eligible for medical, dental, and vision insurance.

Part-time temporary employees receive 6 days of paid sick leave each year (pro-rated for new hires throughout the year).

All US employees who work in a state or locality with more generous paid sick leave benefits than specified here will receive the benefit of those sick leave laws.

What We Believe

At UST HealthProof, we envision a bold future for American healthcare. Our values are the bedrock beliefs our organization holds dear. They not only define what our brand stands for but also serve as a compass guiding every action and decision.

Guiding Principles

These principles illuminate the path of 'how' we operate. They detail actions and behaviors we much embody to honor our values and achieve our goals.

* Simplicity

Simplifying complexity underlines everything we do-this approach is what makes us unique. We come with an open mind and straightforward approach, cutting our way to the core with measurable and actionable insights.

* Integrity

Integrity is our currency to build relationships. We believe in being open and honest. It is only natural when we have nothing to hide. It demonstrates that we are here to do the right thing, no matter who is watching.

* People-Centricity

Everything that we do reflects our deep bonds with peers and customers. These aren't mere transactions, but transformational ties. They shape our culture and decisions, affirming that our true value lies in the lives we touch and impact.

* Leadership

Taking ownership is about taking initiative, being in-charge and driving things to completion. It's a brave choice to 'own' all aspects of our work, ensuring we take full responsibility for everything we handle.

Mission

A future possible only when health plans are free from administrative burdens so they can truly focus on what matters more - their members' well-being.

Equal Employment Opportunity Statement

UST HealthProof 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, disability, status as a protected veteran, or any other applicable characteristics protected by law. We will consider qualified applicants with arrest or conviction records in accordance with state and local laws and "fair chance" ordinances.

UST HealthProof reserves the right to periodically redefine your roles and responsibilities based on the requirements of the organization and/or your performance.

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