Managed Services - BOS - Appeals & Grievances - Sr Manager_Operate

To really stand out and make us fit for the future in a constantly changing world, each and every one of us at PwC needs to be a purpose-led and values-driven leader at every level. To help us achieve this we have the PwC Professional; our global leadership development framework. It gives us a single set of expectations across our lines, geographies and career paths, and provides transparency on the skills we need as individuals to be successful and progress in our careers, now and in the future.  

As an AGMS Manager, you'll work as part of a team of problem solvers, helping to resolve complex business issues from strategy to execution. PwC Professional skills and responsibilities for this management level include but are not limited to:  

• Use feedback and reflection to develop self awareness, personal strengths and address development areas. 

• Delegate to others to provide stretch opportunities, coaching them to deliver results. 

• Demonstrate critical thinking and the ability to bring order to unstructured problems. 

• Use a broad range of tools and techniques to extract insights from current industry or sector trends. 

• Review your work and that of others for quality, accuracy and relevance. 

• Know how and when to use tools available for a given situation and can explain the reasons for this choice. 

• Seek and embrace opportunities which give exposure to different situations, environments and perspectives. 

• Use straightforward communication, in a structured way, when influencing and connecting with others. 

JOB OVERVIEW 

The Manager role is a leadership position that brings in-depth appeals and grievances process and regulatory knowledge, critical thinking and leadership to create distinctive value for AGMS and its clients while creating a culture of individual ownership and accountability for high performance. A Manager is responsible for the daily oversight of the appeals and grievances function to ensure appeals, grievances, complaints, and complex issues from members and providers (or authorized representative) are investigated and resolved using client policies, processes and regulatory guidance in a timely manner in accordance with the standards and requirements established by the Centers for Medicare and Medicaid. The Manager is provides direct supervision to the AGMS team in order to ensure operational effectiveness and compliance with client policies, procedures and government regulations. The Manager is responsible for establishing and monitoring processes to oversee and coordinate the identification, documentation, reporting, investigation and resolution of all member and provider appeals and grievances in a timely and culturally-appropriate manner. The Manager coordinates, tracks, and resolves internal and external appeal and grievance cases for the health plan, including identifying opportunities for improvement related to health plan business processes. This position will be a role model for integrity and will establish and maintain effective professional work relationships, working collaboratively with all levels of management and business owners to help guide the discipline of planning, organizing, securing, managing, leading, and controlling resources to achieve specific goals. Manages aspects of running an efficient team, including supervising, coaching, training, disciplining, and motivating direct-reports. All tasks related to this position are to be done in a manner consistent with AGMS policies, procedures, quality standards, customer needs and applicable local, state and federal regulations.  

Years of Experience 

• Minimum Years of Experience: 2+ years leadership experience in managed care health plan in experience with member appeals, member complaints, provider payment appeals, provider payment disputes, customer service, utilization management, medical management, claims, regulatory affairs / compliance, and 3+ years in healthcare claims review and/or member dispute resolution. 

Responsibilities: 

As a Manager, you’ll work as part of a team of problem solvers with consulting and industry experience, helping our clients solve their complex member, provider and business issues.  

Specific responsibilities include, but are not limited to: 

• Manage and oversee the handling of member and provider appeals and grievances, including providing subject matter guidance and quality assurance reviews of cases. 

• Responsible for timely daily operations in the A&G team. 

• Manage staff, including, but not limited to: monitoring of day to day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others.  

• Establishes and oversees processes and all relevant member and provider correspondence for accuracy, clarity, and cultural appropriateness and sensitivity.  

• Review and monitor procedures for identifying health plan root causes of issues and work collaboratively with cross-functional departments to appropriately address and resolve member and provider appeals and grievances.  

• Serve as a Key Contact for State Fair Hearings, internal and external audits, regulator (CMS, State agency) inquiries.  

• Ensures timely appeal and grievance reporting to regulatory agencies, internal Compliance Department, internal Oversight Committees, etc. 

• Collaborates with cross-functional departments to ensure the use of appropriate appeal and grievance issue codes, timely resolution, and refers to vendor partners as appropriate.  

• Participate and provide representation of the A&G Team at Internal and External meetings/ workgroups and acts as a point person for A&G Programs. 

• Execute on strategic opportunities to improve the overall appeals & grievance process. 

• Partner with internal and external stakeholders to build and maintain collaborative relationships and partnerships.  

• Provide input into the development of automation to guide the team to process efficiencies for all lines of business while maintaining compliance and manageable workloads for staff.  

• Responsible for maintaining and updating on an annual basis, or as necessary, appeal and grievance policies and procedures, member correspondence, etc., consistent with regulatory changes.  

• Develop and maintain inventory reports for the appeals process ensuring appropriate productivity, compliance, and inventory management.  

• Identify and implement continuous business process improvement recommendations to leverage organizational added value to the Appeals and Grievances Department.  

• Maintain a team of top talent, providing a culture of teamwork and collaboration.  

• Perform other duties as assigned.  

Required Knowledge and Skills 

• Operational appeals and grievances experience in a managed care setting, preferably Medicare or Medicaid. 

• Operational managed care experience (call center, appeals or claims environment) in a leadership capacity. 

• Strong verbal and written communication skills, including letter writing experience.  

• Language skills: 

• Excellent English skills with the ability to read, comprehend, write and communicate verbally with stakeholders & customers. 

• Proficiency in Spanish as a first or second language would be preferred. 

• Experience working with firm deadlines, regulators, detail oriented with the ability to interpret and apply regulations. 

• Experience building relationships with organizations and business partners.  

• Ability to multi-task, set priorities and pay attention to details. 

• Ability to successfully interact with members, medical professionals, health plan and government representatives. 

• Knowledge of operational managed care terminology. ICD-10 and CPT codes a plus 

• Proficiency with Microsoft Word, Excel, and PowerPoint.  

• Excellent organizational, interpersonal and time management skills.  

• Must be detail-oriented and an enthusiastic team player.  

• Knowledge of Pega computer system a plus.  

• Preferred experience with appeals and grievances 

Desired Knowledge and Skills 

• Health claims processing background, including coordination of benefits, subrogation, and eligibility criteria. 

• Familiarity with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials. 

Professional and Educational Background 

• The candidate should be graduate in any discipline or an equivalent amount of related work experience is required. 

• At least 2+ years of management level operations leadership experience. 

• Prefer 3+ years of healthcare, preferably health plan, experience in: 

• Member appeals, member complaints, provider payment appeals, provider payment disputes, or 

• Customer service, or 

• Utilization management, or 

• Medical management, or 

• Claims, or 

• Regulatory affairs / compliance 

Additional Information 

• Shift timings: Flexible to work in night shifts (US Time zone) 

• Experience Level : 9-12 years. 

• Mode of working: Work from office 

• Line of Service: Advisory 

• Designation: Manager 

• Location: Hyderabad