Why BayCare?
At BayCare, we are proud to be one of the largest employers in the Tampa Bay area. Our network consists of 16 community-based hospitals, a long-term acute care facility, home health services, outpatient centers and thousands of physicians. With the support of more than 30,000 team members, we promote a forward-thinking philosophy that's built on a foundation of trust, dignity, respect, responsibility and clinical excellence.
Summary:
- Accountable for the daily oversight and performance of key operational areas, including Appeals & Grievances (A&G), Call Center Services, and Intake functions supporting both A&G and Utilization Management (UM).
- Responsible for driving operational excellence, ensuring regulatory and accreditation compliance, and supporting member and provider satisfaction.
- Leads a team of frontline staff and is responsible for ensuring timely case resolution, accurate documentation, and consistent service delivery that meets CMS and NCQA standards.
- In addition to operational supervision, responsible for reporting, quality oversight, and contributing to continuous process improvement initiatives.
- Supports audit readiness, manages NCQA-required functions such as timely processing of grievances and appeals, and partners with Quality and Compliance teams to ensure adherence to policies and performance standards.
- Key responsibilities include supervise and support staff responsible for A&G processing, Call Center interactions, and Intake operations for A&G and UM.
- Ensures all grievance and appeal cases are processed within CMS and NCQA timeframes, with appropriate documentation and member/provider communication.
- Monitors daily productivity and performance metrics; escalates issues that may impact compliance or turnaround times.
- Develops and maintain dashboards, operational reports, and case tracking tools to support internal monitoring and external reporting requirements.
- Oversees quality assurance reviews to ensure accuracy, consistency, and compliance across all operational areas.
- Collaborates with Compliance and Quality teams to support NCQA accreditation standards, including documentation audits, quality improvement initiatives, and reporting requirements.
- Participates in internal and external audits, including preparation of required documentation and process evidence.
- Identifies training needs and facilitates knowledge transfer to ensure staff competency and regulatory understanding.
- Supports root cause analysis and the implementation of corrective action plans related to service failures, compliance findings, or quality variances.
- Fosters a culture of accountability, service excellence, and continuous improvement within the team.
Minimum Qualifications:
Education:
- High School Diploma or GED - Required
- Associate's degree in healthcare administration, Business, or related field; Bachelor's Degree strongly preferred or equivalent combination of education and experience.
Experience:
- Minimum 4 years of experience in Healthcare Operations in a Medicare Advantage or Managed Care setting
- Minimum 2 years of supervisory or team lead experience in a regulated Healthcare environment
Facility: BayCare Health System, Admin - Non Hospital Related-BHS
Location: 300 Park Place Blvd. Clearwater, Fl 33759Status: Full Time, Exempt: YesWeekend Work: None
On Call: No
How often will this team member be working remotely? Hybrid - 1 day/week - 1 day/month in office depending on business needs
Equal Opportunity Employer Veterans/Disabled