24 Sep
Director Medicare Grievance & Appeals
California, Walnutcreek 00000 Walnutcreek USA

Vacancy expired!

Description SHIFT: Day JobSCHEDULE: Full-timeYour Talent. Our Vision. At Anthem, Inc., it’s a powerful combination, and the foundation upon which we’re creating greater access to care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care. This is an exceptional opportunity to do innovative work that means more to you and those we serve at one of America's leading health care companies and a Fortune Top 50 Company. Director Medicare Grievance & Appeals Responsible for departmental workload, processing grievances and appeals in adherence to CMS and Anthem policies. Will plan, direct, and evaluate the investigation, resolution, and response to Medicare/CMS regarding grievance and appeals while ensuring regulatory compliance requirements are met.Primary duties may include, but are not limited to:

Maintains and coordinates Medicare Business staff activities to achieve departmental and corporate company goals in improving service to customers and assuring regulatory compliance.

Directs the activities of all Part A, B, D, re-determinations; Independent Review Entity (IRE) and Administrative Law Judge (ALJ) appeals; clerical error re-openings

Responsible for data mining & reporting, identifying opportunities for improvement and consistency of decisions, and the CMS quality and timeliness standards.

Has frequent and regular contact with various representatives of CMS

Overseeing staffing requirements and productivity

Drives innovation throughout the unit to reduce the overall costs associated with performing the production activities of the team.

Manages the development of systems and processes in support of program activities. Supports initiatives to improve root cause of grievances and appeals and implementing action plans for improvement.

Analyzes and develops strategies to achieve performance thresholds within budgetary guidelines.

Ensures that processes and procedures support overall Quality Improvement program requirements, meets regulatory compliance and/or accreditation and Company standards.

Provides quality control services by monitoring work results of direct reports.

Performs audits to monitor efficiency and compliance with policies.

Plans and executes financial objectives, and forecasts staffing needs.

Hires, trains, coaches, counsels, and evaluates performance of direct reports.

This position may work from any Anthem location. Qualifications This position may work from any Anthem location.

Requires a BS /BA degree in a related field; 5 years of managed care operations experience; 5-8 years management/leadership experience; or any combination of education and experience that would provide an equivalent background.

Active registered Nurse license preferred.

Experience with Medicare CMS, Medicare Grievance & Appeals and delegate oversight preferred.

Knowledge of CMS appeals process and regulations.

Some travel required.

Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and has been named a 2019 Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran. REQNUMBER: PS39230

Vacancy expired!


Related jobs

Report job