VP, Grievance & Appeals

Summary of Position

• Lead the enterprise, multi-state Grievances and Appeals operations such that the team delivers accurate and timely decisions
to members and providers as it pertains to clinical and administrative appeals, payment disputes as well as complaints
regarding quality of service and experience.
• Develop, maintain, and ensure production and quality standards are met and audit outcomes are achieved.
• Establish and implement policies and procedures, evaluating on an ongoing basis to ensure alignment with regulatory
requirements, contractual obligations, and business objectives.
• Ensure compliance with all state and federal appeals and grievances with effective monitoring and quality programs.
• Identify trends across EmblemHealth and delegated Grievance & Appeals unit(s); Develop action plans to address process
and/or systemic failures. Drive cross-functional teams (operations, product, clinical, vendor and executive teams) to
determine areas of improvement.
• Provide oversight and direction for actions and process changes across all operational functions (Membership, Provider
Network Operations, Claims, Customer Service, Utilization Management Operations, Pharmacy Operations, Grievance &
Appeal), delegated and non-delegated, to improve performance to achieve and maintain 5 STAR ratings and high
member/provider satisfaction.
• Partner with enterprise Chief Medical and Chief Operating Officers to ensure clinical programs are operationalized, in
compliance with our Medical Policies and are executed within regulatory timeframes – all to improve Emblem’s Medical
Expense Ratio (MER).
• Serve as a primary liaison with Centers for Medicare & Medicaid Services, Department of Health, Department of Labor,
Department of Financial Services, National Committee for Quality Assurance and the Attorney General.
• Lead Operations Business Support team, responsible for implementation and maintenance of business, accreditation
contractual and regulatory requirements, ensuring that EmblemHealth and their delegates are aligned. Manage multiple
complex implementations necessary for EmblemHealth to achieve and maintain business and quality outcomes, contractual
requirements and compliance with regulatory requirements.
• Develop and coordinate with EmblemHealth Operations tower leads and internal business areas to ensure that monitoring
and associated monitoring plans effectively measure business and compliance requirements.
• Lead the coordination of all internal, client and regulatory audits within Operations, ensuring timely submission of all audit
deliverables. Provide overall audit support including quality review of all submissions include universes and corrective action
plans.
• Direct Oversight of Pharmacy Operations to ensure the appropriate servicing of members and providers as it pertains to the
enterprise pharmacy benefits.
• Ensure best in class contact center, maintaining or exceeding service levels as required per regulations and clientele, while
consistently monitoring to ensure that call center operations are efficient and effective using key performance indicators and
a metrics driven culture.
• Leverage technology to receive and respond to customer inquiries creatively and effectively.
• Provide strategic and budget leadership in annual operating plans. 

Principal Accountabilities

• Create long-term strategies that provide enterprise level guidance.
• Create enterprise awareness of competitive trends and capabilities.
• Make significant contributions towards EmblemHealth’s short and long-term business initiatives: deliver operations within
budget and in the most administrative efficient way.
• Identify, hire, & train staff members, developing them into strong leaders and creating high-performing, self-directed teams.
Effectively plan for succession planning ensuring talent pipeline.
• Act as change agent to drive and effect organizational change ensuring key deliverables are met.
• Deliver 5 STAR performance of Grievance & Appeals specifically: Plan Makes Timely Appeal Decisions about Appeals; Clinical
decision-making; identify, hire, & train staff members, developing them into strong leaders and creating high-performing,
self-directed teams.