Grievances and Appeals Supervisor


Community Health Group is a locally based non-profit health plan that ensures access to high quality, culturally sensitive health care for underserved communities throughout San Diego County. We treat our 300-member, multi-lingual staff like family, encouraging an atmosphere of collaborative teamwork, continuous learning, personal growth, and promotion from within. Recognized as one of the Top Workplaces in San Diego, CHG offers its employees such benefits as tuition reimbursement, a meditation room and yoga classes, a monthly Breakfast With The CEO, and memorable events throughout the year. 

We know that by serving our employees well, they, in turn, will better serve our nearly 300,000+ membership. We have been recognized consistently for the excellence and sensitivity of our customer service by members, physicians, vendors, and a full range of health care providers. We are accredited by the National Committee for Quality Assurance and proud of our continuing company-wide Quality Initiatives.

We are currently recruiting for:

Grievances and Appeals Supervisor

POSITION SUMMARY

Ensures that all grievances and appeals filed by or on behalf of members are processed in accordance with regulatory protocols and internal policies and procedures.  Works closely with the Quality Improvement (QI) department and with other departments as needed to obtain necessary information related to the grievance or appeal.  Works closely with Community Services staff on the orientation and training of providers and appropriate internal staff.

 

COMPLIANCE WITH REGULATIONS

Works closely with the QI department and with all other departments necessary to ensure that the processes, programs and services are accomplished in a timely and efficient manner in accordance with CHG policies and procedures and in compliance with applicable state and federal regulations including Centers for Medicare and Medicaid Services (CMS) and/or Medicare Part D, Department of Managed Health Care (DMHC) and Department of Health Care Services (DHCS).

 

RESPONSIBILITIES

  • Responsible for ensuring that the grievance and appeals system and QI system is clearly understood and followed by all applicable staff.

  • Addresses and resolves all non-quality of care grievances within specified time lines and procedures.  Coordinates with the QI department to ensure all Potential Quality Improvement (PQI) issues are addressed within specified timelines and procedures.

  • Ensures appropriate remedial action to members' grievances by working closely with appropriate staff to ensure that all member grievances, appeals and PQIs are processed in accordance with regulatory requirements and internal policies and procedures.

  • Works closely with Community Services staff when internal or external operational issues identified during the resolution of any given grievance or appeal.

  • Educates primary care providers by providing orientation and training on CHG’s complaint and grievance system. 

  • Assists in the gathering of reports/documents related to DHCS, DMHC, NCQA and CMS program audits, including review of records with auditing team. On a quarterly basis develops a grievance and appeals report and present the findings and/or trends during the SQIC and Public Policy committee meeting.

  • Uses Innovare software to capture all needed data and run all required internal and regulatory reports.

  • Will prepared monthly written report to the Operations committee meeting as needed.

  • Maintains product and company reputation and contributes to the team effort by conveying professional image and accomplishing related tasks; participating on committees and in meetings; performing other duties as assigned or requested.

  • Develops quarterly grievance and appeals reports (and other related reports) for regulatory agencies:  DMHC, CMS, and DHCS.

     

EDUCATION

  • Bachelor’s Degree.

     

    EXPERIENCE/SKILLS

  • Five years’ experience in Customer Service and/or related field.

  • Ability to read, analyze and interpret regulations and contract language.

  • Experience with and sensitivity to cultural background and linguistic needs of our membership and customer service skills.

  • Ability to exercise independent and sound judgment.

  • Knowledge and familiarity with services available through community-based organizations in San Diego.

  • Strong technical writing skills and analytical skills.

     

    PHYSICAL REQUIREMENTS

  • Prolonged periods of sitting and frequent walking.

  • May be required to work evenings and weekends.

  • Some driving may be required