Company Statement
EmblemHealth is one of the nation’s largest not for profit health insurers, serving members across New York’s diverse communities with a full range of commercial and government-sponsored health plans for employers, individuals, and families. With a commitment to value-based care, EmblemHealth partners with top hospitals and doctors, including its own AdvantageCare Physicians, to deliver quality, affordable, convenient care. At over a dozen EmblemHealth Neighborhood Care locations, members and non-members alike have access to community-based health and wellness guidance and resources. For more information, visit emblemhealth.com.
Supervisor, Grievance & Appeals
🔍 New York, New York
Summary of Job
Responsible for overseeing the day-to-day operations of the Grievance and Appeal Specialists, ensuring adherence to department performance standards and operational efficiency. Continuously improve the effectiveness and efficiency of operations in the assigned unit, utilize working knowledge of all G&A areas to ensure that the department is fully compliant with all government regulations. Monitor staff to ensure adherence to all department and company policies. Work with other departments to maximize cooperative relationships; act as an interface with others for excellent customer service and process improvement.
Responsibilities
- Manage the day-to-day operations of the staff including new hires.
- Ensure the appropriate staff responds to all member/provider inquiries within the stipulated time frames, thereby ensuring member/provider satisfaction and compliance.
- Have accountability for all performance issues and take appropriate action as warranted. Maintain coverage for expedited appeal files on weekends and holidays to ensure EmblemHealth remains complaint as applicable.
- Responsible for identification and root cause analysis of appeal issues, working with applicable business areas to resolve issues.
Review daily/weekly pend reports to ensure that proper research is being performed and timeframes are met. - Review quality audits on staff files to effectively evaluate performance and ensure compliance.
- Work with staff as needed to improve performance: monitor attendance and punctuality; complete performance reviews; conduct weekly staff meetings to encourage open communication and build team morale.
- Manage delegate relationships (Beacon, HCP, CMO, EviCore, etc.); collaborate with them to develop workflows, resolve appeal and grievance issues and implement quality improvements.
- Create and implement policies and procedures to ensure that department goals are met using the most efficient and cost-effective measures. Participate in creating and implementing continuous process and quality improvement initiatives while fostering a team environment to maintain a high performing unit.
- Conduct root cause analysis: implement process improvements based on findings. Prepare for internal/external audits.
- Participate in the recruitment of qualified candidates for all open positions and arrange and monitor the training process for new staff members. Monitor staff performance and address any problems during the probationary period.
- Regular attendance is an essential function of the job; perform other duties as assigned or required.
Qualifications:
- Bachelor’s Degree
- 4 – 6+ years of relevant, professional work experience (Required)
- 1 – 2+ years of managed care experience (Required)
- Staff/process management experience (Preferred)
- Additional experience/specialized training may be considered in lieu of educational requirement (Required)
- Knowledge of EmblemHealth’s programs, and of the department’s web-based programs (Preferred)
- In-depth knowledge of grievance and appeal processes, federal /state regulations, and contractual/processing guidelines (Required)
- Proficient in MS Office (Word, Excel, PowerPoint, Outlook, Teams, etc.) (Required)
- Supervisory skills sufficient to direct, motivate, and discipline staff (Required)
- Analytical and technical ability to review and analyze procedures and workflow and to make recommendations for streamlining the grievance and appeals process within the functional units of the department (Required)
- Strong communication skills (verbal, written, presentation, interpersonal) with all types/levels of audience (Required)
- Ability to organize, prioritize, and effectively manage multiple tasks/projects with competing priorities/deadlines (Required)
- Proven ability to manage a heavy workload in a dynamic, fast paced environment (Required)
- Ability to problem solve, make appropriate decisions, and seek assistance when necessary (Required)
Security Disclosure
If you receive a job offer from EmblemHealth, the email will be from “HRTalentAcquisition” with the subject: “Offer of Employment for (job title) – Please respond online.” We will never ask you to join a Google Hangout, buy your own equipment, or pay to apply. We also do not use third-party email services like Yahoo or Gmail.
Pay Disclosure
At EmblemHealth, we prioritize transparency in our compensation practices. We provide a good faith estimate of the salary range for potential hires, which is based on key factors such as role responsibilities, candidate experience, education and training, internal equity, and market conditions. Please be aware that this estimate doesn’t account for geographic differences related to your work location. Typically, new hires may not start at the top of this range, as compensation is tailored to each individual's circumstances. For union positions, salaries will be determined according to the collective bargaining agreement. Join us at EmblemHealth, where your contributions are valued and supported by fair compensation.
EEOC Statement
We value the diverse backgrounds, perspectives, and experiences of our workforce. As an equal opportunity employer, we consider all qualified applicants for employment regardless of race, color, religion, sex, sexual orientation, gender identity, pregnancy, marital status, national origin, disability, veteran status, or any other protected characteristic protected by law.
Sponsorship Statement
EmblemHealth may provide work visa sponsorship depending on factors such as business unit requirements, position nature, costs, and applicable laws and regulations.