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Manager, Appeals & Grievances
Supv LocationINDEPENDENCE
Posting Closes
SupervisorCandice McGee
Job Code170315
DepartmentAPPEALS
  
Job Responsibilities
GEHA is an Equal Opportunity Employer with five locations in the Kansas City metropolitan area. Our company's corporate headquarters is located in Lee's Summit near Douglas Rd and I-470. The claims processing office and call center is located in Independence near Little Blue Parkway and I-70. All offices are easily accessible by freeway from anywhere in the Kansas City metro area.

Open Positions: 1
Location: Independence, MO (Landmark Building)

Summary
Responsible for managing day-to-day operation, orientation and evaluation of the Supervisor, Appeals & Grievance, team leads, reconsideration specialists and correspondence representatives. Coordinates the responses to all inquiries from members and providers. Supervises responses to all Office of Personnel Management (OPM) inquiries. Analyzes disputed claims trends and appeals. Notifies senior management of identified patterns or trends. Ensures business processes are consistent with industry standard practices.

Duties

• Foster and maintain a collaborative relationship with internal and external customers to ensure customer satisfaction. Work with business partners to identify ways to improve business processes.

• Plan, develop, and manage the quality and production of the Appeals & Grievance team, coordinate issues with the Director, Business Operations.

• Promote consistency and accuracy within the department processes and compliance with OPM requirements, HIPAA guidelines and general accreditation requirements as well as internal protocols.

• Ensure the Supervisor, Appeals & Grievance continually improves performance and meets organizational/division performance goals. Implements action plans to increase quality and productivity.

• Meet with team on a regular basis and share responsibility for resolving opportunities/issues and to communicate business objectives and results.

• Works closely with all GEHA internal teams which may include Care Management, Pharmacy, Claims, and Provider Network Management to ensure procedures are consistent with contractual benefits, established policies and procedures are followed, and to negotiate solutions and resolve conflicts.

• Responsible for oversight of maintenance and updating appeal policy and procedures, member correspondence materials and contractual changes. Identify issues and root causes of appeals and disputes for plan management and compliance. 

• Play a leadership role by implementing action plans to support an increase in quality and productivity.

• Communicate business objectives and results.

• Negotiate solutions and resolves conflicts.

• Anticipate and handle critical situations.

• Meet with teams on a regular basis and share responsibility for resolving opportunities/issues.

• Motivate individuals and team to provide exceptional service.

• Maintain a positive work environment that supports high performing teams and rewards people based on performance.

• Work to create a performance improvement/development plan that focuses on increasing job competency.

• Address strategies to attract, develop and retain staff.

• Provide coaching based on productivity and quality results and develop improvement plans when needed.

• Provide strategic guidance for all areas of accountability.

• Prepares and monitors department budget and expenditures.

• Other duties as assigned.

Education Requirements
Requires a Bachelor’s degree in Business or a related field.  Additional years of qualifying work experience may be considered in lieu of formal education.

Experience Requirements
Requires six (6) years of progressively responsible health plan experience with at least three (3) years of health plan leadership experience and staff responsibility.  Requires highly effective verbal and written communication skills and good organizational skills are necessary to respond to inquiries and communicate with OPM personnel.  Demonstrated experience in developing, communicating and implementing key performance metrics to enhance continuous functional improvement.  Requires thorough knowledge of medical terminology, medical codes and related reference materials.  Incumbent is required to obtain knowledge of GEHA’s Affirmation Action policy and to make decisions regarding employment, promotion, and termination of employees that comply with its principles.