Responsible for clinical oversight and direction for a complex, multi-faceted and high-volume grievance and complaint unit. Provides oversight and direction to staff including meeting customer, state, and federal regulations for processing grievances and complaints, meeting time requirements, working in the development processes and procedures for continuous quality improvement. Responsible for supervision and oversight of clinical and non-clinical Grievance and Complaint department staff and responsible for team growth. Responsible for compliance with Utilization Review Accreditation Commission (URAC), National Committee for Quality Assurance (NCQA) and applicable state license requirements.
Manages day-to-day grievance and complaint operations, ensuring program and procedures support company strategic priorities for service, quality, and cost effectiveness as well as compliance with contract, accreditation, federal and state requirements.
Manages the grievance and complaint program to align with clinical programs along with conducting activities that address the impact of grievance and complaint findings such as trends of issues, overturn rates, customer delegation requirements, and provider and member satisfaction.
Oversees the grievance and complaint investigation process to ensure that summaries meet needs and requirements set by the health plan Medical Directors.
Oversees the staff to ensure that case reviews and grievance resolutions are accurate, reliable, complete, and timely and provides expertise with data analysis.
Communicates across various departments and understands the strategic impact of the grievance and complaint programs for the company and how the grievance and complaint program integrates with other business initiatives.
Responsible for maintaining current knowledge of state regulations, accreditation standards, and customer contracts and promoting system efficiencies.
Responsible for determining severity levels for Quality of Care (QOC) and Potential Quality Issues (PQI).
Responds to member, provider, and client inquiries regarding status, process and outcome of grievances and complaints. Consults with staff on problem cases and interfaces with all departments in resolving issues.
Other Job Requirements
Responsibilities
7+ years of relevant experience in appeals/grievances/complaints in the state of the applicable contract.Licensed clinician in state of supported contract required.Ability to receive assignments in the form of high-level objectives and independently establish detailed goals to meet objectives.Strong interpersonal skillsExcellent verbal and written communication skills.Ability to function independently and as a team member.Good organization and time management skills with the ability to manage multiple tasks simultaneously.Proven ability to plan, organize, schedule, direct, control and monitor project activities.
General Job Information
Title
Sr Grievance Manager - Remote in CA
Grade
27
Work Experience - Required
Grievances, Healthcare, Management/Leadership
Work Experience - Preferred
Health Plans
Education - Required
Bachelors - Nursing, Masters - Counseling, Masters - Social Work
Education - Preferred
License and Certifications - Required
LCSW - Licensed Clinical Social Worker - Care Mgmt, LPCC - Licensed Professional Clinical Counselor - Care Mgmt, RN - Registered Nurse, State and/or Compact State Licensure - Care Mgmt
License and Certifications - Preferred
Magellan Health, Inc. is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled.Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their position; and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.
Magellan is the employer of choice for hard working people interested in making a difference in the health care industry and in the communities where we work and live. Our strong culture of caring is the common thread in both our business strategy and our work environment. We value professional growth and development, total health and wellness, rewards and recognition as well as employee unity. Magellan is a place where you can thrive.
Magellan is committed to providing equal employment opportunities to employees and applicants for employment without regard to race, color, creed, religion, sex, gender identity and expression, sexual orientation, marital status, age, national origin, ancestry, citizenship, physical or mental disability, disabled veteran or veteran of the Vietnam Era status, or any other factors protected by law.
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