Director, Appeals and Grievance

City/State

Work Shift

Overview:

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 Plans (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

• Bachelors Degree (Required)

Location

• Remote

Experience

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

Benefits: Caring For Your Family and Your Career

Medical Dental Vision plans

Adoption Fertility and Surrogacy Reimbursement up to $10000

Paid Time Off and Sick Leave

Paid Parental & Family Caregiver Leave

Emergency Backup Care

Long-Term Short-Term Disability and Critical Illness plans

Life Insurance

401k/403B with Employer Match

Tuition Assistance $5250/year and discounted educational opportunities through Guild Education

Student Debt Pay Down $10000

Pet Insurance
Legal Resources Plan
Colleagues have the opportunity to earn an annual discretionary bonus ifestablished system and employee eligibility criteria is met.

Sentara Health is an equal opportunity employer and prides itself on the diversity and inclusiveness of its close to an almost 30000-member workforce. Diversity inclusion and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves.

In support of our mission to improve health every day this is a tobacco-free environment.

For positions that are available as remote work Sentara Health employs associates in the following states:

Alabama Delaware Florida Georgia Idaho Indiana Kansas Louisiana Maine Maryland Minnesota Nebraska Nevada New Hampshire North Carolina North Dakota Ohio Oklahoma Pennsylvania South Carolina South Dakota Tennessee Texas Utah Virginia Washington West Virginia Wisconsin and Wyoming.