Supervisor, Appeals & Grievances Job Listing at Medical Mutual in OH (Job ID 2400244)

Description

This is a remote position. Note, quarterly/ad-hoc/situational on-site requirement in Brooklyn, Ohio. Eastern & Central Time Zones preferred.

Founded in 1934, Medical Mutual is the oldest and one of the largest health insurance companies based in Ohio. We provide peace of mind to more than 1.6 million Ohioans through our high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement, and individual plans.

Supervises operations and staff responding to written/verbal grievances, complaints, and appeals submitted by commercial or government health plan members and providers. Ensures compliance with federal and state regulations and contractual guidelines.

Responsibilities

·         Supervises the intake, investigation and resolution of appeals and grievances/complaints, for members and providers, ensuring compliance with regulatory and contractual processes and timeframes for assigned commercial or government product line.

·         Monitors workloads and workflow. Ensures grievances, appeals, and complaints are processed, prioritized, and resolved within regulatory and contractual requirements and timeframes.

·         Ensures the integrity of documentation and tracking for each appeal, complaint and/or grievance. This may include Centers for Medicare & Medicaid Services (CMS), National Committee for Quality Assurance (NCQA), and Department of Insurance reporting. Analyzes data and identifies trends and recommends improvements.

·         Participates in various internal and external meetings such as Compliance, Stars Advisory Group, audit, and regulatory meetings, etc.

·         Participates in the development and implementation of policies, procedures and operational workflows related to complaints, grievances, and appeals. Stays aware of regulatory changes and recommends changes to processes and procedures based on those changes.

·         Participates on projects and/or teams. Collaborates with other areas of the division and/or corporation regarding customer problems and trends, and relays pertinent information to departmental personnel.

·         Performs oversight duties for vendors as required.

·         Participate in internal and external audit, including review and preparation of files/universes and answering questions posed by auditors.

·         Performs other duties as assigned.

Qualifications

Education and Experience

·         Bachelor's Degree in healthcare or business administration or related discipline, or equivalent combination of education/training and experience.

·         7 years progressive experience as an Appeals/Customer Resolution Specialist or equivalent experience in customer service executive/escalation response in a health plan.

·         Medicare/Medicaid experience preferred.

Technical Skills and Knowledge

·         Knowledge of medical terminology, provider reimbursement, and medical claims.

·         Knowledge of health insurance products and services.

·         Ability to communicate with all levels.

·         Strong oral, written, and interpersonal communication skills.

·         Strong analytical skills.

·         Intermediate to advanced Microsoft Office and claims operation system skills.

Medical Mutual is looking to grow our team! We truly value and respect the talents and abilities of all of our employees. That's why we offer an exceptional package that includes:

A Great Place to Work:

• We will provide the equipment you need for this role, including a laptop, monitors, keyboard, mouse and headset.
• Whether you are working remote or in the office, employees have access to on-site fitness centers at many locations, or a gym membership reimbursement when there is no Medical Mutual facility available. Enjoy the use of weights, cardio machines, locker rooms, classes and more.
• On-site cafeteria, serving hot breakfast and lunch, at the Brooklyn, OH headquarters.
• Discounts at many places in and around town, just for being a Medical Mutual team member.
• The opportunity to earn cash rewards for shopping with our customers.
• Business casual attire, including jeans.

Excellent Benefits and Compensation:

• Employee bonus program.
• 401(k) with company match up to 4% and an additional company contribution.
• Health Savings Account with a company matching contribution.
• Excellent medical, dental, vision, life and disability insurance — insurance is what we do best, and we make affordable coverage for our team a priority.
• Access to an Employee Assistance Program, which includes professional counseling, personal and professional coaching, self-help resources and assistance with work/life benefits.
• Company holidays and up to 16 PTO days during the first year of employment with options to carry over unused PTO time.
• After 120 days of service, parental leave for eligible employees who become parents through maternity, paternity or adoption.

An Investment in You:

• Career development programs and classes.
• Mentoring and coaching to help you advance in your career.
• Tuition reimbursement up to $5,250 per year, the IRS maximum.
• Diverse, inclusive and welcoming culture with Business Resource Groups.

About Medical Mutual:

Medical Mutual's status as a mutual company means we are owned by our policyholders, not stockholders, so we don't answer to Wall Street analysts or pay dividends to investors. Instead, we focus on developing products and services that allow us to better serve our customers and the communities around us.

There's a good chance you already know many of our Medical Mutual customers. As the official insurer of everything you love, we are trusted by businesses and nonprofit organizations throughout Ohio to provide high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement and individual plans. Our plans provide peace of mind to more than 1.2 million Ohioans.

We're not just one of the largest health insurance companies based in Ohio, we're also the longest running. Founded in 1934, we're proud of our rich history with the communities where we live and work.

At Medical Mutual and its family of companies we celebrate differences and are mutually invested in our employees and our community. We are proud to be an Equal Employment Opportunity and Affirmative Action Employer. Qualified applicants will receive consideration for employment regardless of race, color, religion, sex, sexual orientation, gender perception or identity, national origin, age, marital status, veteran status, or disability status.

We maintain a drug-free workplace and perform pre-employment substance abuse and nicotine testing.