Supervisor-Grievance and Appeals
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Samaritan Health Plans (SHP) provides health insurance options to Samaritan employees, community employers, and Medicare and Medicaid members. SHP operates a portfolio of health plan products under several different legal structures: InterCommunityHealth Plans, Inc. (IHN) is designated as a regional Coordinated Care Organization (CCO) for Medicaid beneficiaries; Samaritan Health Plans, Inc. offers Medicare Advantage, Commercial Large Group, and Commercial Large Group PPO and EPO plans; SHP is also the third-party administrator for Samaritan Health Services’ self-funded employee health benefit plan.
As part of an Integrated Delivery System, Samaritan Health Plans is strategically and operationally aligned with Samaritan Health Services’ mission of Building Healthier Communities Together.
This is a remote position in which we are able to employ in the following states: Alabama, Alaska, Arizona, Arkansas, Connecticut, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Carolina, Oklahoma, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, or Wisconsin
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JOB SUMMARY/PURPOSE
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Accountable for leading Samaritan Health Plan Operations appeals and grievance functions. Ensures timely, accurate, and appropriate responses to inquiries, grievances, and appeals from members, providers, and regulators for all LOB. Responsible for the staffing, development, guidance and daily supervision of the Grievance and Appeals team. Performs administrative support to investigate and resolve member complaints, member grievances and provider disputes. Performs initial and ongoing staff training in necessary skills and knowledge base, and assists leadership to maximize both outcomes and operational efficiency of the team. Works collaboratively with other operational leaders to identify process opportunities and improve processes. Ensures regulatory compliance at all times.
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DEPARTMENT DESCRIPTION
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Samaritan Health Plans (SHP) operates a portfolio of health plan products under several different legal structures: InterCommunity Health Plans, Inc. (IHN) is designated as a regional Coordinated Care Organization (CCO) for Medicaid beneficiaries; Samaritan Health Plans, Inc. offers Medicare Advantage, Commercial Large Group, and Commercial Large Group PPO and EPO plans; SHP is also the third-party administrator for Samaritan Health Services’ self-funded employee health benefit plan. As part of an Integrated Delivery System, Samaritan Health Plans is strategically and operationally aligned with Samaritan Health Services’ mission of Building Healthier Communities Together.
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EXPERIENCE/EDUCATION/QUALIFICATIONS
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Bachelor's degree in a related field or equivalent experience required.
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Four (4) years health plans or health insurance experience required, with a minimum of two (2) years experience specific to Grievances and Appeals.
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Previous leadership experience required.
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Experience and/or training in computer applications, including Microsoft Word, Excel, and PowerPoint, required.
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Experience with reporting software tools, FACETS, Crystal Reports, and other software applicable to Grievance and Appeals preferred.
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KNOWLEDGE/SKILLS/ABILITIES
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Effective written and verbal communication skills to perform group presentations, tactfully discuss issues, and listen to and understand concepts, rules and procedures. Ability to work with all levels within the organization, facilitate communication, and effectively document related activities.
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Analytical and organizational skills. Ability to identify complex problems, review related information, employ creativity and alternative thinking to develop and evaluate options and implement solutions.
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Leadership - Inspires, motivates, and guides others toward accomplishing goals. Achieves desired results through effective people management.
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Ability to meet deadlines.
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PHYSICAL DEMANDS
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Rarely
(1 - 10% of the time)Occasionally
(11 - 33% of the time)Frequently
(34 - 66% of the time)Continually
(67 – 100% of the time)CLIMB - STAIRS
LIFT (Floor to Waist: 0"-36") 0 - 20 Lbs
LIFT (Knee to chest: 24"-54") 0 – 20 Lbs
LIFT (Waist to Eye: up to 54") 0 - 20 Lbs
CARRY 1-handed, 0 - 20 pounds
BEND FORWARD at waist
KNEEL (on knees)
STAND
WALK – LEVEL SURFACE
ROTATE TRUNK Standing
REACH - Upward
PUSH (0 - 20 pounds force)
PULL (0 - 20 pounds force)
SIT
CARRY 2-handed, 0 - 20 pounds
ROTATE TRUNK Sitting
REACH - Forward
MANUAL DEXTERITY Hands/wrists
FINGER DEXTERITY
PINCH Fingers
GRASP Hand/Fist
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