Director, Appeals & Correspondence- Rockville, MD
Company Name:
Kaiser Permanente
The Dir of Appeals & Correspondence is a key leader w/in KP's Mid-Atlantic (KPMAS) Health Plan Srvs Admin (HPSA) who ensures timely, accurate & appropriate responses to inquiries, grievances & appeals from members, external providers & regulators. The Dir also facilitates the identification & resolution of srv gaps that contribute to both customer & member dissatisfaction & are a source of unnecessary appeals cases or create employer group retention issues. Provides overall management & direction to Regional Member Srvs Correspondence Center. Oversight responsibility of case processing (Complaints, Grievances & Appeals). Ensures Health Plan compliance w/county, state & federal regulatory & accreditation agencies. Sets the strategic direction, operational vision & implementation of all functions of the Correspondence Center. Builds effective working relationships & collaborates w/partners in the Member Srv Organization, Permanente Medical Groups, Regional Depts & Sr Leadership.
Essential Functions:
- Directs the Appeals & Correspondence unit in researching & responding to member/provider appeal or grievance cases & responds to inquiries from State & Federal regulatory agencies. Ensures that responses are provided in a timely & accurate manner & meet regulatory requirements for a given line of business. Serves as HP representative for Fair Hearings, Maximus or other regulatory entities.
- Collaborates w/the Mid-Atlantic Permanente Medical Group (MAPMG), HPSA, Legal & other KPMAS Depts to ensure that appeals cases, grievances & inquiries are resolved in an appropriate manner that balances the needs of the customer w/policies of the health plan in compliance w/regulatory requirements & NCQA guidelines.
- Fosters a culture of continuous process improvement w/in the Appeals & Correspondence team to support the evolving needs for process improvement w/in the health plan for servicing our members & customers.
- Identifies, gathers, & analyzes appeals or grievance data to improve the performance of the Appeals & Correspondence unit, as well as identify opportunities for process improvement. Leads initiatives for change based on data findings. Establishes & monitors metrics to ensure compliance w/regulatory requirements & sustain strong performance.
- Collaborates w/MAPMG, HPSA, & other KPMAS Depts to take advantage of process improvement or retention opportunities identified through analysis of appeals cases.
- Monitors changes in Federal & State regulations by KPMAS line of business & adjusts Appeals & Correspondence processes to ensure continued compliance.
- Participates in legislative mandate & RQIC committee activities to ensure compliance w/regulatory requirements & deliverables.
- Demonstrated Mgmt & leadership skills, including working w/varied levels of staff, budgeting, delegation, staff development, coaching resource allocation planning, & performance Mgmt.
- Demonstrated ability in development of team focus, partnership, srv orientation, influence & change leadership. Demonstrated expertise in results orientation, taking initiative.
- Actively acknowledges & provides reward & recognition to unit staff.
- Outstanding interpersonal/communication skills w/ability to effectively partner w/a wide group of stakeholders.
- Demonstrated awareness in emotional intelligence as modeled in day-to day leadership responsibilities.
- Ability to use sound judgment & to handle potentially charged issues independently w/knowledge & ability to escalate & obtain assistance when needed.
- Demonstrated knowledge regarding Health Care regulation & compliance standards, internal policies & procedures.
- This job description is not all encompassing.
Qualifications:
Basic
Qualifications:
Experience
- Ten (10) years of experience in health care or health insurance administration, required.
- Seven (7) years of management/ supervisory experience within a large, complex organization with at least six (6) years in a health care organization.
- Five (5) years of experience in leading process improvement initiatives to improve operational performance.
- Two (2) years of experience in healthcare appeals, grievances or correspondence management required.
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:
- Experience with OPM, CMS and Mid Atlantic State regulations governing healthcare organizations
- 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 Dir of Appeals & Correspondence is a key leader w/in KP's Mid-Atlantic (KPMAS) Health Plan Srvs Admin (HPSA) who ensures timely, accurate & appropriate responses to inquiries, grievances & appeals from members, external providers & regulators. The Dir also facilitates the identification & resolution of srv gaps that contribute to both customer & member dissatisfaction & are a source of unnecessary appeals cases or create employer group retention issues. Provides overall management & direction to Regional Member Srvs Correspondence Center. Oversight responsibility of case processing (Complaints, Grievances & Appeals). Ensures Health Plan compliance w/county, state & federal regulatory & accreditation agencies. Sets the strategic direction, operational vision & implementation of all functions of the Correspondence Center. Builds effective working relationships & collaborates w/partners in the Member Srv Organization, Permanente Medical Groups, Regional Depts & Sr Leadership.
Essential Functions:
- Directs the Appeals & Correspondence unit in researching & responding to member/provider appeal or grievance cases & responds to inquiries from State & Federal regulatory agencies. Ensures that responses are provided in a timely & accurate manner & meet regulatory requirements for a given line of business. Serves as HP representative for Fair Hearings, Maximus or other regulatory entities.
- Collaborates w/the Mid-Atlantic Permanente Medical Group (MAPMG), HPSA, Legal & other KPMAS Depts to ensure that appeals cases, grievances & inquiries are resolved in an appropriate manner that balances the needs of the customer w/policies of the health plan in compliance w/regulatory requirements & NCQA guidelines.
- Fosters a culture of continuous process improvement w/in the Appeals & Correspondence team to support the evolving needs for process improvement w/in the health plan for servicing our members & customers.
- Identifies, gathers, & analyzes appeals or grievance data to improve the performance of the Appeals & Correspondence unit, as well as identify opportunities for process improvement. Leads initiatives for change based on data findings. Establishes & monitors metrics to ensure compliance w/regulatory requirements & sustain strong performance.
- Collaborates w/MAPMG, HPSA, & other KPMAS Depts to take advantage of process improvement or retention opportunities identified through analysis of appeals cases.
- Monitors changes in Federal & State regulations by KPMAS line of business & adjusts Appeals & Correspondence processes to ensure continued compliance.
- Participates in legislative mandate & RQIC committee activities to ensure compliance w/regulatory requirements & deliverables.
- Demonstrated Mgmt & leadership skills, including working w/varied levels of staff, budgeting, delegation, staff development, coaching resource allocation planning, & performance Mgmt.
- Demonstrated ability in development of team focus, partnership, srv orientation, influence & change leadership. Demonstrated expertise in results orientation, taking initiative.
- Actively acknowledges & provides reward & recognition to unit staff.
- Outstanding interpersonal/communication skills w/ability to effectively partner w/a wide group of stakeholders.
- Demonstrated awareness in emotional intelligence as modeled in day-to day leadership responsibilities.
- Ability to use sound judgment & to handle potentially charged issues independently w/knowledge & ability to escalate & obtain assistance when needed.
- Demonstrated knowledge regarding Health Care regulation & compliance standards, internal policies & procedures.
- This job description is not all encompassing.
Qualifications:
Basic
Qualifications:
Experience
- Ten (10) years of experience in health care or health insurance administration, required.
- Seven (7) years of management/ supervisory experience within a large, complex organization with at least six (6) years in a health care organization.
- Five (5) years of experience in leading process improvement initiatives to improve operational performance.
- Two (2) years of experience in healthcare appeals, grievances or correspondence management required.
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:
- Experience with OPM, CMS and Mid Atlantic State regulations governing healthcare organizations
- 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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