Company Statement
For the last 80 years, EmblemHealth has been taking care of New York’s heart and soul, its people. Today, health care is more complex than ever. That’s why we’re at the forefront of change. We work alongside our customers to offer access to high-quality, affordable care, help navigate the health care experience, and make good health achievable; because everyone deserves to be taken care of. We deliver on our mission every day by living our values with our colleagues, members, clients and partners. It begins with caring and respecting all those we work with. We believe a culture of diversity and inclusion is vital to serve our unique and diverse customers. We seek for continues improvement and innovation and believe being agile and nimble is our advantage. We bring a strong sense of partnership to every relationship – internally and externally. The EmblemHealth family of companies offers competitive health, welfare, and retirement benefits as well as incentive pay plans and more.
Director, Grievance & Appeals Regulatory Complaints
Summary of Position
Direct oversight of the Regulatory Complaint functions, ensuring compliance with all regulatory, state and federal guidelines
for all product lines. Research and implement methods to improve the effectiveness and efficiency of operations in the unit. Responsible for completion and monitoring of all internal and regulatory related reporting. Identify regulatory complaint trends, performing root cause analysis and implementing corrective actions as required. Work with internal department leadership to construct corrective actions in response to regulatory complaints, ensuring
resolutions best support our internal processes and resources and are implemented in a timely fashion.
Responsibilities:
Departmental Operations:
• Direct oversight of Regulatory Complaints processing.
• Ensure that department goals are being met efficiently and effectively.
• Monitor daily reports to ensure that all timeframes are met to maximize member and provider satisfaction.
• Responsible for ensuring timely and accurate responses to all regulatory complaints.
• Ensure the accuracy and resolution of all cases includes handling of the underlying issue reported on the complaint.
• Communicate with CMS/State regional office liaison on a regular basis.
Research and Problem Solving:
• Research and resolve all issues presented to the Plan by regulatory agencies.
• Responsible for identification and root cause analysis of complaints.
• Determine action plans and work with affected area to implement corrective action.
• Understand, assess, and provide resolution of the overall member and provider impact of identified issues.
• Continuously measure effectiveness of corrective action.
Other Management Functions:
• Participate in meetings and present to committees to represent the Grievance and Appeal Department.
• Ensure that all quarterly, mid-year and annual performance reviews are conducted for management staff.
• Provide guidance, training, and motivation to staff.
• Create and manage relationships with all applicable regulatory oversight bodies.
Audits and Reporting:
• Responsible for submission of all internal and regulatory related reporting.
• Responsible for accurate preparation and execution of all internal and regulatory audits, including submission of
universe, review of audit findings, and the development and implementation of any required corrective actions.
• Develop required reporting for various committees, providing analysis of receipts and outcomes.
Policy and Procedure:
• Conduct training with staff on new and/or updated policies and procedures.
• Provide interpretation and guidance to staff.
• Regular attendance and demonstrated flexibility are essential functions of the job.
• Perform other duties as assigned or required.
Qualifications:
- Bachelors’ degree
- 10 years’ experience in a healthcare or customer service-related field required
- 5 years’ staff and process/operational management experience required
- Ability to interpret and implement federal, state and local guidelines for all aspects of the member and provider process required
- Ability to review and analyze procedures and workflows and to make process streamlining recommendations required
- Excellent organization and interpersonal skills are required to interact effectively with all levels of staff required
- Ability to work under pressure and prioritize a heavy workload in a dynamic fast paced environment required
- Ability to perform tasks with a sense of urgency; submitting assignments in a timely manner required
- Strong analytical and technical ability; and attention to detail required
- Proven ability to establish and maintain relationships of trust with departmental staff and management required
- Proven ability to coordinate and lead interdepartmental work teams and meet established goals required
- Demonstrated ability to lead and motivate staff; and affect change required
Security Disclosure
If you are offered a job from one of the EmblemHealth family of companies that includes ConnectiCare, AdvantageCare Physicians, and WellSpark, the offer confirmation email will come from “HRTalentAcquisition” with the subject line: “Offer of Employment for (job title)” – Please respond online”.
We never ask you to join a Google Hangout, request you to purchase your own equipment or pay to apply. We do not send email from a third-party email service such as Yahoo or Gmail.
Pay Disclosure
A good faith estimate of the compensation range for individuals hired to work for the EmblemHealth Family of Companies is provided. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate’s work experience, education/training, internal peer equity, and market and business considerations. The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. It is not typical for an individual to be hired at or near the top of the range, as compensation decisions depend on each case’s facts and circumstances. Union roles covered by a collective bargaining agreement will compensate in accordance with the union contract.
EEOC Statement
We are committed to leveraging the diverse backgrounds, perspectives, and experiences of our workforce to create opportunities for our people and our business. We are an equal opportunity/affirmative action employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex/gender, sexual orientation, gender identity or expression, pregnancy or related condition, marital status, national origin, disability, protected veteran status or any other characteristic protected by law.
Sponsorship Statement
Depending on factors such as business unit requirements, the nature of the position, cost and applicable laws and regulations, EmblemHealth may provide work visa sponsorship for certain positions.