Manager, Health Plan Business Operations – Grievances and Appeals
Denver Health
full-time
Posted on:
Location Type: Hybrid
Location: Denver • Colorado • United States
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Salary
💰 $86,800 - $134,500 per year
About the role
- Managing health plan operations and regulatory compliance with emphasis on grievances and appeals.
- Overseeing review, investigation, documentation, processing, negotiating and resolving disputed medical insurance claims per federal and state regulatory requirements.
- Facilitating and participating in internal monitoring for compliance and regulatory audits.
- Providing oversight for administrative functions and management of the department, including personnel and financial management.
- Analyzing and evaluating service for quality improvement including productivity, strategic planning, budget management, and development of performance standards.
- Supervising staff training and managing productivity to ensure effective and balanced case workload.
- Building and managing effective partnerships that engage stakeholders in understanding the issues, identifying opportunities and assisting with resolution.
- Ensuring that department's milestones/goals are met and adhering to approved budgets.
Requirements
- Associate's Degree from an accredited school in business, healthcare or related field required OR Bachelor's degree from an accredited school in business, healthcare or related field preferred
- 4-6 years previous grievance and appeals experience including various lines of business including Medicare, Medicaid, CHP and Exchange preferred
- OR 4-6 years health plan operations including project and/or professional management in areas such as billing/finance regulations, planning & development, setting operational objectives, human resource management and business forecasting required
- AND 1-3 years health insurance claims processing and/or cross functional health insurance experience such as experience involving claims, enrollment, utilization management and/or finance preferred
- Health insurance claims processing knowledge - specifically QNXT experience valued
- Requires strong organizational skills to set priorities and ability to work with high degree of accuracy and attention to details while responding to tight deadlines and multiple priorities and demands.
- Able to lead, manage, advise, mentor, direct and evaluate employees with grace, fairness and accountability.
- Values and attributes that show empathy, display resilience and show sound judgement in claims management.
- Build and manage effective partnerships that engage stakeholders in understanding the issues, identifying innovative solutions and in supporting best practice claim management outcomes.
- Highly skilled in budget preparation/financial analysis, decision making regarding appropriateness of care review, assist with research design planning, and analyzing and generating quality improvement reports.
- Ability to work independently as well as collaboratively with other internal and external team members to ensure timelines are met.
- Knowledge of personnel management, management of budgets, strategic planning involving collaboration with outside agencies or business entities.
- Ability to communicate and maintain effective working relationships with subordinates, medical staff, administration, and other departments.
- Knowledge and problem-solving process.
- Extraordinary emotional intelligence and quotient, professional communications, interpersonal skills and ability to build genuine trust relationships throughout the organization and beyond.
Benefits
- Outstanding benefits including up to 27 paid days off per year
- Immediate retirement plan employer contribution up to 9.5%
- Generous medical plans
- Free RTD EcoPass (public transportation)
- On-site employee fitness center and wellness classes
- Childcare discount programs & exclusive perks on large brands, travel, and more
- Tuition reimbursement & assistance
- Education & development opportunities including career pathways and coaching
- Professional clinical advancement program & shared governance
- Public Service Loan Forgiveness (PSLF) eligible employer+ free student loan coaching and assistance navigating the PSLF program
- National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
grievance and appeals experiencehealth plan operationshealth insurance claims processingbudget preparationfinancial analysisproject managementhuman resource managementbusiness forecastingstrategic planningquality improvement
Soft Skills
organizational skillsleadershipmentoringempathyresiliencejudgmentcollaborationcommunicationinterpersonal skillsemotional intelligence
Certifications
Associate's DegreeBachelor's Degree