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Grievance Supervisor

HealthSun Health Plans • Miami, FL

Posted 30 days ago

Job Snapshot

Full-Time
Experience - At least 5 year(s)
Degree - 4 Year Degree
Insurance
Health Care
Relocation - No

Job Description

HealthSun Health Plans www.healthsun.com is seeking energetic,talented and qualified professionals to join us in our mission of changing the healthcare experience of our members - making it easier, friendlier and more accessible. If you are looking for a challenging and rewarding career with a chance to make a real difference in your community, please apply.


HealthSun Health Plans is headquartered in the Coconut Grove area of Miami, Florida supporting the needs of Medicare Advantage recipients throughout South Florida. We are proud to offer outstanding career advancement opportunities, competitive salaries, paid holidays, medical & dental insurance plans, vacation/sick/personal time, and disability benefits.


Responsible for providing support and guidance to Grievance Coordinators and managing the Grievance process to ensure resolution in a timely manner in accordance with established regulatory guidelines.

ESSENTIAL DUTIES & RESPONSIBILITIES:

  • Coordinates new hire training and provides guidance to coordinators.
  • Understands Part C and Part D grievance classifications and provide member resolutions with a response that is in accordance to contract benefits and CMS guidelines.
  • Prints daily report(s)and prioritize work based on classifications and member necessity.
  • Investigates all parties involved and responds to written or verbal grievances submitted by members and providers in accordance with Contract Benefits and CMS and DOH regulations.
  • Obtains all necessary supporting documentation for all Part C and Part D grievances and/or involve administration to assist in providing an accurate explanation.
  • Determines the appropriate type of service and facilitates a resolution to member’s grievance with provider.
  • Investigates and responds appropriately and within time guidelines.
  • Presents cases for review and documenting all relevant information and/or any changes recommended.
  • Ensures the proper handling of member complaints whether presented by members, their authorized representative, the Ombudsman office, state contractors, member advocates, providers, etc.
  • Ensures that CMS requirements are completed for each type of grievance such receipt, investigated and grievance is fully resolved, surrogate/proxy forms and letters are attached.
  • Guides all other grievance coordinators with any concerns or questions that relates to the grievance process.
  • Handles escalated calls and assist with the resolution process.Assists with reporting, project planning or process improvement.
  • Understands grievances policies and procedures.
  • Responds to grievance in writing when deemed a quality of care or when received in writing within 30 days.
  • Requests 14 day grievance extension when it is in the best interest of the beneficiary.
  • Reviews assigned cases on a daily basis.
  • Conducts thorough reviews of each grievance response provided by the provider network and  ensure that each response meets CMS regulations.
  •  Meets with Grievance & Appeals Manager on a regular basis to: provide feedback on departmental and staff issues/opportunities; staffing requirements and needs; receive feedback on own performance.
  • Reviews overtime report and ensures communication with staff as appropriate. 
  • Communicates effectively with other professional and support staff in order to achieve positive customer outcomes. 
  • Promotes and contributes to a positive, problem-solving environment.
  • Assists customers, family members and others with concern and empathy; respect their confidentiality, privacy, and communicate with them in a courteous and respectful manner. 
  • Complies with company policies and procedures and maintains confidentiality of customer medical records in accordance with state and federal laws. 
  • Ensures compliance with all HIPAA, OSHA, and other federal, state, and local regulations. 
  • Participates in meetings, training and in-service education, as required.
  • Perform other duties as assigned.            

Job Requirements

  • Minimum of High School diploma or equivalent 
  • Bachelor’s Degree in Health Care Administration or related field from an accredited college or university preferred
  • 5+ years of prior experience in customer service in a healthcare setting is required
  • Minimum of 2 years experience in investigating and resolving grievances in a managed care organization is required
  • Minimum of two years’ experience in leadership role
  • Demonstrated leadership and management skill required
  • Ability to explain difficult concepts in a clear, logical, and engaging way
  • Ability to respond to challenges with patience, empathy, and tenacity
  • Working knowledge of the Privacy and Security Health Insurance Portability and Accountability Act (HIPAA) regulations is preferred
  • Excellent computer knowledge is required, including proficient knowledge of Microsoft Office
  • Ability to successfully interact with members, physicians, medical representatives and other medical professionals
  • Must be patient in dealing with an elderly population and sympathetic to hearing or vision deficiencies
  • Ability to work effectively independently and in a team environment
  • Ability to read, analyze, and interpret technical procedures or governmental regulationsAbility to write reports, business correspondence, and procedure manuals
  • Ability to effectively present information and respond to questions from groups of managers, clients, customers and the general public
  • Ability to calculate figures and amounts, such as discounts, interest, commissions, proportions, percentages, area and volume
  • Ability to define problems, collect data, establish facts, and draw valid conclusions
  • Strong decision-making and analytical skills
  • Must be self-motivated, organized and have excellent prioritization skills
  • Must be able to work well under stressful conditions
  • Must be able to work in a fast paced environment
  • Fluency in Spanish and English required

HealthSun Health Plans and its affiliated companies is an equal opportunity/affirmative action employer and complies with all federal and state laws, regulations and executive orders regarding affirmative action requirements in all programs.M/F/D/V.

HealthSun and its affiliates are also a drug-free workplace.

*Internal candidates must submit the Internal Application Form approved by his/her supervisor before interviewing with HR. Qualified candidates will be considered by the Hiring Manager.


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