The Manager of CA&G will oversee the appropriate handling of member and provider complaints, grievances and appeals for multiple lines of business including Medicare, Health Exchange, US Family Health Plan, Medicaid, and CHIP. The Manager will ensure compliance with regulatory and accreditation requirements and support company initiatives and processes related to member and provider satisfaction and Medicare STARS. The Manager will work closely with other members of CHRISTUS Health Plan senior management to ensure high quality, minimal risk, and compliant operations.
MAJOR JOB RESPONSIBILITIES
Prepare for and represent CAG in all audits, interviews and compliance meetings including those facilitated by NCQA, CMS, DHA, OSI, HHSC, TDI.
Oversee the resolution of member complaints, appeals, and grievances related to the quality of care and service, medical necessity, plan benefits and payments to ensure compliance with state and federal regulations and NCQA standards.
Report data and make recommendations to the appropriate internal committees and workgroups such as Quality Improvement Committee, Provider Monitoring, and STARS Program Steering Committee.
Analyze complaint, appeal, and grievance data, develop trend reports and work with various committees to identify opportunities for improvement and increase member and provider satisfaction.
Oversee the investigation and resolution of provider disputes/appeals involving provider terminations, credentialing denials and claim denials according to state regulations.
Monitor delegated vendor complaint, appeal, and grievance activity to ensure compliance. Partner with other business areas through the Delegated Vendor Oversight Committee or other similar groups to identify issues and develop appropriate action plans to address deficiencies.
Develop, update and maintain corporate policies and procedures to support new lines of business and reflect changes in contract language and updates in regulations and standards.
Develop and maintain collaborative relationships with internal and external customers.
Design and implement company-wide training and in-services to ensure quicker resolution of member issues and a better understanding of member and provider appeal rights.
Manage cross-functional employees to meet and exceed service requirements and functional objectives.
Recruit, develop, motivate and retain a high caliber of team members.
Coach and lead team to continuously improve operational performance.
Maintain a positive work environment that supports self-direction; provide a structure to optimize the experience, skill, knowledge, and capability of the team.
Reward team members based on contribution and performance.
Manage budget and control expenses while meeting operational, financial and service requirements.
Perform other duties as assigned
Follow the CHRISTUS Health guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI).
Attend weekly and monthly team and department meetings as appropriate.
Ability to sit for long periods of time.
Ability to organize and prioritize work to meet deadlines.
Ability to work occasional long or irregular hours.
Ability to work a flexible work schedule including evenings and weekends.
Education and Experience
Bachelor's degree from an accredited institution required; at least eight years of experience in the managed care industry is required; minimum of five years' experience in Appeals is preferred.
Special Skills, Licenses, and Certifications
Highly proficient in applicable business software applications including PC usage, Microsoft Word, PowerPoint, and Excel. Preparation of business plans, analyses, and programmatic and operational reports. Research and program planning methodology. Project Management.
Strong leadership and problem-solving skills. Excellent oral and written communication skills including good grammar, voice, and diction. Ability to read and interpret documents and calculate figures and amounts. Proficient in MS Office with basic computer and keyboarding skills. Excellent organizational skills, ability to prioritize and manage time efficiently and effectively.
Work Environment And Physical Demands
Ability to use a computer keyboard and other business machines. More than 50% of work time is spent in front of a computer monitor.
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.