Quality Manager
Wellvana
Manager, Grievance and Appeals
Microsoft 365
full-time
Posted on:
Origin: • 🇺🇸 United States
Visit company websiteSalary
💰 $120,525 - $150,656 per year
Job Level
Mid-LevelSenior
About the role
- Ensure daily workloads standards and metrics are met
- Responsible for day-to-day leadership/support of department staff
- Facilitate training/development needs for individuals and department
- Implement and maintain G/A technology resources to meet the needs of the business
- Review and prepare reports which monitor performance guarantees to/from Navitus Health Solutions
- Oversee clinical determinations made by departmental clinical staff and responsible for evaluating trends and proposing utilization management changes based on IRO/IRE determinations
- Manage and maintain resources that support G/A staff
- Act as the first point of contact with vendors, clients and internal departments
- Serve as point of escalation and expertise for internal and external customers and independent review vendors (IRO/IRE)
- Maintain relationships with external review organizations, department resources, G/A reporting, tracking, trending and forecasting summaries
- Prepare and present for audits and serve as a technology SME for Navitus systems used by the G/A department
- Ensure department metrics are met through monitoring of staff performance using software including Calabrio, Adobe, Visio, Excel, Crystal, and MS Office applications
Requirements
- A minimum of a Bachelors Degree in Pharmacy or Pharm D
- Current, unrestricted, licensure as an RPh in home state or the ability to gain licensure within 4 months of employment is required
- 3-5 years of managed care and/or insurance background preferred
- Strong knowledge of CMS coverage determination and redetermination processes
- Experience with CMS and/or NCQA audits strongly desired
- 1-3 years of leadership experience preferred
- Knowledge of the PBM industry, formulary management, pharmacy claims and managed care principles and practices is desired
- Proficiency in drug literature and clinical trial evaluation, including proficiency with electronic databases (e.g., Micromedex, Medline, Internet) required
- Ability to reason and translate clinical information into a manner appropriate for clinical systems and clinical/non-clinical audiences
- Requires attention to details in order to assure projects are clinically, editorially, and systems accurate and can be operationalized
- Proficiency in MS Word, Excel, Power Point including tables, charts and figures preferred
- Participate in, adhere to, and support compliance program objectives
- The ability to consistently interact cooperatively and respectfully with other employees
