Team Lead, Grievance & Appeals Resolution (Licensure required)

• Responsible for full resolution of HICS and CTM cases within regulatory timeframes and defined requirements
• Supervise staff for quality review, performance feedback, disciplinary issues and merit/bonus appraisal review
• Meet all monthly, annual and semi-annual reporting deadlines
• Work with Regulatory Compliance Officers to ensure that requests are resolved within time lines and tracked for reporting
• Monitor Marketplace, Medicaid and Medicare processes to ensure that all regulatory requirements are followed
• Work with support departments and compliance officers to ensure policies and procedures are current
• Establish an audit process
• Responsible for evaluating operations and identifying process improvement needs. Identify irregular trends with HICS processes, RCO processes and the CTM system ; work with other areas as appropriate to identify root causes and appropriate steps for resolution
• Responsible for staffing, ensure that open positions are filled, and evaluate future staffing needs
• Review validation reports to ensure that grievances and appeals as it relates to the HICS and RCO processes are accurate
• Develop and monitor workflows for Grievance and Appeals Department as it relates to HICS and RCO processes that ensures maximum level of productivity
• Monitor member-facing departments to ensure that grievances and appeals are resolved and reported to the Grievance and Appeals Department, for HICS and RCO.
• Conduct audits and provide feedback to all areas that submit grievances and appeals, as it relates to the HICS and RCO processes.
• Facilitate timely resolution of member and provider issues.
• Ensure that Grievance and Appeals Specialists for the HICS and RCO processes are available to respond to incoming calls
• Coordinate incoming information and disseminate to staff to ensure accuracy of communication to internal and external customers.
• Create, review, revise and enforce company and departmental policies and procedures
• Act as the contact point for CareSource on operational issues to all regulatory bodies in existing and future lines of business
• Proactively keep the management team apprised of the team’s performance, projects and issues
• Provide support to the Service Center during high call volume or other support as needed
• Develop, deliver or coordinate the delivery of grievance and appeals training to other areas as needed.
• Performs any other job related duties as requested.

• Associates degree in business, finance or related field required
• Bachelor's degree in business, finance or related field preferred
• Equivalent years of relevant work experience may be accepted in lieu of required education
• Four (4) years years of experience in billing, credit and collections, or customer service experience required
• Previous supervisory/leadership experience preferred

• Basic computer skills including Microsoft Word, Excel and PowerPoint
• Basic experience with ACD systems
• Basic experience with Call Management Systems
• Communication skills
• Prior supervisory skills
• Ability to work independently and within a team environment
• Attention to detail
• Familiarity of the healthcare field and knowledge of Marketplace, Medicaid and Medicare.
• Critical listening and thinking skills
• Training/teaching skills
• Strategic management skills
• Negotiation skills/experience
• Proper grammar usage
• Technical writing skills
• Time management skills
• Proper phone etiquette
• Customer service oriented
• Decision making/problem solving skills
• Strong language skills
• Ability to write comprehensive statements using proper grammar and sentence structure

• Current, unrestricted State Insurance License in Accident and Health within state(s) of assigned territory is/are required or ability to achieve license(s) within 30 days of hire
• Applicable certification as required within state(s) of assigned territory or ability to achieve certification(s) within 30 days of hire and annual recertification each year thereafter is required
• For positions in states that operate under the Federally Facilitated Marketplace (FFM) and offer Marketplace plans, candidates must obtain certification from the Health Insurance Marketplace

• General office environment; may be required to sit or stand for extended periods of time
• Up to 15% (Occasional) travel based on the needs of the department may be required

Compensation Range:

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Fostering a Collaborative Workplace Culture

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business