Director, Appeals & Correspondence - Rockville, MD
Company Name:
Kaiser Permanente
The Director of Appeals and Correspondence is a key leader within Kaiser Permanente's Mid-Atlantic (KPMAS) Health Plan Services Administration (HPSA) who ensures timely, accurate and appropriate responses to inquiries, grievances and appeals from members, external providers and regulators. The Director also facilitates the identification and resolution of service gaps that contribute to both customer and member dissatisfaction and are a source of unnecessary appeals cases or create employer group retention issues. Provides overall management and direction to Regional Member Services Correspondence Center. Oversight responsibility of case processing (Complaints, Grievances and Appeals). Ensures Health Plan compliance with county, state and federal regulatory and accreditation agencies. Sets the strategic direction, operational vision and implementation of all functions of the Correspondence Center. Builds effective working relationships and collaborates with partners in the Member Service Organization, Permanente Medical Groups, Regional Departments and Senior Leadership.
Essential Functions:
- Directs the Appeals and Correspondence unit in researching and responding to member/ provider appeal or grievance cases and responds to inquiries from State and Federal regulatory agencies. Ensures that responses are provided in a timely and accurate manner and meet regulatory requirements for a given line of business. Serves as HP representative for Fair Hearings, Maximus or other regulatory entities.
- Collaborates with the Mid-Atlantic Permanente Medical Group (MAPMG), HPSA, Legal and other KPMAS departments to ensure that appeals cases, grievances and inquiries are resolved in an appropriate manner that balances the needs of the customer with policies of the health plan in compliance with regulatory requirements and NCQA guidelines.
- Fosters a culture of continuous process improvement within the Appeals and Correspondence team to support the evolving needs for process improvement within the health plan for servicing our members and customers.
- Identifies, gathers, and analyzes appeals or grievance data to improve the performance of the Appeals and Correspondence unit, as well as identify opportunities for process improvement. Leads initiatives for change based on data findings. Establishes and monitors metrics to ensure compliance with regulatory requirements and sustain strong performance.
- Collaborates with MAPMG, HPSA, and other KPMAS departments to take advantage of process improvement or retention opportunities identified through analysis of appeals cases.
- Monitors changes in Federal and State regulations by KPMAS line of business and adjusts Appeals and Correspondence processes to ensure continued compliance.
- Participates in legislative mandate and RQIC committee activities to ensure compliance with regulatory requirements and deliverables.
- Demonstrated management and leadership skills, including working with varied levels of staff, budgeting, delegation, staff development, coaching resource allocation planning, and performance management.
- Demonstrated ability in development of team focus, partnership, service orientation, influence and change leadership. Demonstrated expertise in results orientation, taking initiative.
- Actively acknowledges and provides reward and recognition to unit staff.
- Outstanding interpersonal/communication skills with ability to effectively partner with a wide group of stakeholders.
- Demonstrated awareness in emotional intelligence as modeled in day-to day leadership responsibilities.
- This job description is not all encompassing.
Qualifications:
Basic
Qualifications:
Experience
- Minimum ten (10) years of experience in health care or health insurance administration, required.
- Minimum four (4) years of experience with OPM, CMS and Mid-Atlantic State regulations governing healthcare organizations.
- Minimum seven (7) years of management/supervisory experience within a large, complex organization with at least 6 years in a healthcare organization.
- Minimum five (5) years of experience in leading process improvement initiatives to improve. operational performance.
Education
- Bachelor's degree required.
License, Certification, Registration
- N/A
Additional Requirements:
- Demonstrated familiarity with HMO policies and procedures.
- Focused on customer service objectives for both members and employer groups as applicable.
- Excellent written and verbal communication skills.
- High proficiency in basic software and system applications (e.g. MS Office Suite, Lotus Notes).
Preferred
Qualifications:
- Prior management/supervisory experience within KPMAS.
- Master's degree preferred.
- Knowledge of KPMAS member/ provider appeals policies and procedures.
External hires must pass a background check/drug screen.
We are proud to be an equal opportunity/affirmative action employer.Estimated Salary: $20 to $28 per hour based on qualifications.
Kaiser Permanente
The Director of Appeals and Correspondence is a key leader within Kaiser Permanente's Mid-Atlantic (KPMAS) Health Plan Services Administration (HPSA) who ensures timely, accurate and appropriate responses to inquiries, grievances and appeals from members, external providers and regulators. The Director also facilitates the identification and resolution of service gaps that contribute to both customer and member dissatisfaction and are a source of unnecessary appeals cases or create employer group retention issues. Provides overall management and direction to Regional Member Services Correspondence Center. Oversight responsibility of case processing (Complaints, Grievances and Appeals). Ensures Health Plan compliance with county, state and federal regulatory and accreditation agencies. Sets the strategic direction, operational vision and implementation of all functions of the Correspondence Center. Builds effective working relationships and collaborates with partners in the Member Service Organization, Permanente Medical Groups, Regional Departments and Senior Leadership.
Essential Functions:
- Directs the Appeals and Correspondence unit in researching and responding to member/ provider appeal or grievance cases and responds to inquiries from State and Federal regulatory agencies. Ensures that responses are provided in a timely and accurate manner and meet regulatory requirements for a given line of business. Serves as HP representative for Fair Hearings, Maximus or other regulatory entities.
- Collaborates with the Mid-Atlantic Permanente Medical Group (MAPMG), HPSA, Legal and other KPMAS departments to ensure that appeals cases, grievances and inquiries are resolved in an appropriate manner that balances the needs of the customer with policies of the health plan in compliance with regulatory requirements and NCQA guidelines.
- Fosters a culture of continuous process improvement within the Appeals and Correspondence team to support the evolving needs for process improvement within the health plan for servicing our members and customers.
- Identifies, gathers, and analyzes appeals or grievance data to improve the performance of the Appeals and Correspondence unit, as well as identify opportunities for process improvement. Leads initiatives for change based on data findings. Establishes and monitors metrics to ensure compliance with regulatory requirements and sustain strong performance.
- Collaborates with MAPMG, HPSA, and other KPMAS departments to take advantage of process improvement or retention opportunities identified through analysis of appeals cases.
- Monitors changes in Federal and State regulations by KPMAS line of business and adjusts Appeals and Correspondence processes to ensure continued compliance.
- Participates in legislative mandate and RQIC committee activities to ensure compliance with regulatory requirements and deliverables.
- Demonstrated management and leadership skills, including working with varied levels of staff, budgeting, delegation, staff development, coaching resource allocation planning, and performance management.
- Demonstrated ability in development of team focus, partnership, service orientation, influence and change leadership. Demonstrated expertise in results orientation, taking initiative.
- Actively acknowledges and provides reward and recognition to unit staff.
- Outstanding interpersonal/communication skills with ability to effectively partner with a wide group of stakeholders.
- Demonstrated awareness in emotional intelligence as modeled in day-to day leadership responsibilities.
- This job description is not all encompassing.
Qualifications:
Basic
Qualifications:
Experience
- Minimum ten (10) years of experience in health care or health insurance administration, required.
- Minimum four (4) years of experience with OPM, CMS and Mid-Atlantic State regulations governing healthcare organizations.
- Minimum seven (7) years of management/supervisory experience within a large, complex organization with at least 6 years in a healthcare organization.
- Minimum five (5) years of experience in leading process improvement initiatives to improve. operational performance.
Education
- Bachelor's degree required.
License, Certification, Registration
- N/A
Additional Requirements:
- Demonstrated familiarity with HMO policies and procedures.
- Focused on customer service objectives for both members and employer groups as applicable.
- Excellent written and verbal communication skills.
- High proficiency in basic software and system applications (e.g. MS Office Suite, Lotus Notes).
Preferred
Qualifications:
- Prior management/supervisory experience within KPMAS.
- Master's degree preferred.
- Knowledge of KPMAS member/ provider appeals policies and procedures.
External hires must pass a background check/drug screen.
We are proud to be an equal opportunity/affirmative action employer.Estimated Salary: $20 to $28 per hour based on qualifications.
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