Director, Appeals and Grievance

Overview

The Director of Appeals and Grievance will plan, develop, and direct the department services and activities for all existing and new business opportunities. This includes setting strategic long- term goals for Commercial, Medicaid, and Medicare business. This role assumes leadership for the program development and strategic planning of for Appeals and Grievance Department in all Sentara Health Plan’s (formally known as Optima Health) lines of business and markets.

• Develops policies, workflows, and compliance documents, which meet all contractual, regulatory and accreditation requirements for new and existing business product lines.
• Provide oversight for complaints, appeals and grievances reporting and analysis, and interface with Member Services on ongoing key performance indicators
• Oversee staff in their efforts to resolve and coordinate resources effectively to solve any needs for ad hoc requests and ongoing projects relative to appeals and grievances, state, federal, and accreditation requirements
• The Director works closely with the Medical Directors to identify trends in Appeals and make recommendations to change Medical Criteria and Benefit covered items.
• Accountable for ensuring compliance with contractual agreements, SHP policies and procedures in addition to Federal, State and Accreditation regulations and standards.
• Responsible for all external audits of Appeals and Grievance: NCQA, EQRO, CMS, DMAS and BOI.
• Responsible to meet department SLAs and work with other departments to ensure full compliance with targets.
• Responsible for effective management of work inventories and establishing and maintaining working relationships with other departments.
• Responsible for the outcomes of the Appeals and Grievance department.
• Support inquiries from Compliance and Internal Audit including development and execution of corrective action plans with a focus on issues recurrence avoidance.
• Other tasks as needed for the success of the department and Sentara Health Plans

Education

• Bachelor\'s Degree (Required)

Location

• Remote

Experience

• Minimum five years of experience with Healthcare Complaints/Appeals.