Grievance & Appeals Operations Manager

About SCAN

SCAN Group is a not-for-profit organization dedicated to tackling the most pressing issues facing older adults in the United States. SCAN Group is the sole corporate member of SCAN Health Plan, one of the nation's leading not-for-profit Medicare Advantage plans, serving more than 285,000 members in California, Arizona, Nevada, and Texas. SCAN has been a mission-driven organization dedicated to keeping seniors healthy and independent for more than 40 years and is known throughout the healthcare industry and nationally as a leading expert in senior healthcare. SCAN employees are a group of talented, passionate professionals who are committed to supporting older adults on their aging journey, while also innovating healthcare for seniors everywhere. Employees are provided in-depth training and access to state-of-the-art tools necessary to do their jobs, as well as development and growth opportunities. SCAN takes great pride in recognizing our team members as experts in their fields and rewarding them for their efforts. If you are interested in becoming part of an organization that is innovating senior healthcare visit www.thescangroup.org, www.scanhealthplan.com, or follow us on LinkedIn; Facebook; and Twitter.

The Job

To oversee and manage the grievance and appeals process, ensuring timely, fair, and compliant resolution of cases while maintaining high standards of customer service and adherence to regulatory requirements.

You Will

• Ensure alignment to and achievement of the organizations goals by managing and overseeing the Grievance and Appeals Department's day-to-day operations and productivity.
• Ensure completion of required activities for grievance, appeal and complaint functions within the required timeframes by establishing and maintaining effective workflow, systems, tools and monitoring processes and by performing necessary process improvements.
• Ensure staff performance by acting as the first line resource for staff and assisting in problem solving specific issues as well as improving systems and tools, implementing and maintaining proper staffing including use of temporary staff.
• Ensure compliance with and adhere to all regulatory and quality standards including but not limited to: Centers for Medicare and Medicaid Services (CMS), Department of Managed Health Care (DMHC), Department of Health Care Services (DHCS), and Department of Managed Health Care (DMHC) as it relates to the Grievance and Appeal Department activities by establishing and maintaining processes for understanding, training to, and monitoring adherence to the standards and by preforming necessary process improvements to address areas of identified non-compliance.
• Ensure staff is trained to review incoming inquires for both Medicare Part C and Part D, determine case classification, and prepare cases for review by either the Pharmacist or the Medical Director following SCAN and department policies and procedures to achieve organizational goals and outcomes.
• Ensure environment and culture of teamwork by facilitating staff meetings and interdisciplinary team meetings.
• Ensure that department policies and procedures, desktop procedures, workflows, job aides, and training materials, are current and accurately reflect processes in order to provide consistent quality care and comply with regulatory requirements.
• Partner with stakeholders and department management to create and review department metric reporting for productivity and efficacy to support organizational vision and goals.
• Function as the department subject matter expert and represent department at assigned committees to support two-way communication.
• Interface with HCS Medical Director to ensure quality case review occurs in accordance with department policy and procedures.
• Maintain staff by recruiting, selecting, orienting, and training employees; maintaining a safe and secure work environment; and developing personal growth opportunities.
• Actively support the achievement of SCAN's Vision and Goals.
• Other duties as assigned.

Your Qualifications

• Bachelor's Degree in Healthcare or human service-related field of study or equivalent experience
• 5+ years in managed health care setting, Medicare/Medicaid Grievance and Appeals preferred.
• Working knowledge of guidelines and regulations relevant to Grievance and Appeals including Medicare, Medi-Cal, DMHC, DHCS, and NCQA Guidelines.
• Excellent presentation skills, group motivation and supervisory skills.
• Strong strategic planning, critical thinking and leadership skills.
• Demonstrated management experience.
• Experience with coordinating diverse groups of individuals to achieve success of the overall program.

What's in it for you?

• Base Pay Range: $80,300.00 - $128,500.00 (Annually)
• Work Mode: Mostly Remote
• An annual employee bonus program
• Robust Wellness Program
• Generous paid-time-off (PTO)
• 11 paid holidays per year, plus 1 additional floating holiday
• Excellent 401(k) Retirement Saving Plan with employer match
• Robust employee recognition program
• Tuition reimbursement
• An opportunity to become part of a team that makes a difference to our members and our community every day!

We're always looking for talented people to join our team! Qualified applicants are encouraged to apply now!

At SCAN we believe that it is our business to improve the state of our world. Each of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits, and more.

SCAN is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.

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