Grievance Supervisor

About the role

Grievance work involves complex coordination, investigation and specific resolution(s) within regulatory timeframes. Areas of Grievance work include: Appeals: A member complaint involving an adverse benefit determination by an Alliance Utilization Management (UM) decision. Member Grievances (Complaints) : An oral or written statement submitted by a member or a member's authorized representative expressing dissatisfaction with any aspect of the Alliance's health care plan. Expedited Appeals/ Grievances: A complaint or Appeal involving an imminent and serious threat to the health of the member, as determined by an Alliance Medical Director that includes, but is not limited to, severe pain, potential loss of life, limb or major bodily function. State Fair Hearings: The process whereby a member enrolled in Medi-Cal requests the Department of Social Services (DSS) and its Administrative Law Division to resolve Plan decisions that deny, modify or delay health care services or affect Medi-Cal benefits. Inquiries: A question or request for information or assistance by a member that does not reflect the member's dissatisfaction with any aspect of the Alliance's health care plan. Complex Member Billing Issues or Member Reimbursements: When an Alliance member receives a bill from a medical provider for covered services or paid out of pocket for covered Medi-Cal services. Interdepartmental Collaboration: Grievance collaborates with each department within the Alliance to complete investigations for Grievance cases. Cases are routed to Subject Matter Experts (SMEs) in other departments to support the investigation and resolution. Grievance relies on SMEs to clearly document within the Grievance System: the steps of their investigation, the determination of each case and whether the Alliance's initial determination of an action was upheld or overturned. This thorough and neutral review ensures the proposed resolution, outlined in the letter, meets contractual and regulatory requirements. Oversight of the Grievance Process: The Chief Executive Officer is the Plan Officer responsible for oversight of the grievance process. Grievance cases and trends are shared and discussed during monthly Staff Grievance Review Committee (SGRC) meetings. SGRC members include SMEs, managers and directors from various Alliance departments. Grievance volume and trends are also reported on a quarterly basis to the Quality Improvement and Health Equity Workgroup (QIHEW), Quality Improvement and Health Equity Committee (QIHEC), and as needed to the Compliance Committee. WHAT YOU'LL NEED TO BE SUCCESSFUL To read the full position description, and list of requirements click here . Knowledge of: The principles and practices of healthcare coverage and benefit structures, the principles of coordination of benefits, and medical billing Medi-Cal program and related regulations Title 22 and Title 28 utilization management and grievance regulations Principles and practices of customer service Principles and practices of managed health care Ability to: Act as technical resource and explain regulations, processes, and programs related to area of responsibility Learn, interpret, and apply Medicare D-SNP regulations and act as a subject matter expert on D-SNP within the Grievance Unit Supervise, train and evaluate the work of staff M