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MGR, APPEALS

Company: Sentara Health
Location: Chesapeake
Posted on: January 9, 2022

Job Description:

Job Description

Assumes responsibility, accountability and leadership for the daily operations of the Complaints & Appeals Department of Sentara Health Plans (SHP), including policies, process, coordination of work, timeliness, quality and service. Performs administrative reviewsensuring that all research and documentation is complete for timely and accurate resolution of member complaints and member/provider appeals. The Manager works with the Medical Directors of the Health Plan as well as other appropriate individuals and departments to conduct investigations of customer complaints and appeals. Accountable for ensuring compliance with contractual agreements and SHP policies and procedures in addition to Federal, State and Accreditation regulations and standards. Supports and communicates Sentara Healthcare's mission, values, and goals and provides direction and oversight to departmental staff. Additional Duties Include:

Monitors trends and analyzes grievance and appeals data for submission to appropriate parties.

Mentors unit and other departments for complex issues and interpretation of regulatory standards.

May perform internal audits of grievance and appeals process.

Hires, trains, coaches, counsels, and evaluates performance of direct reports.

Job Posting

Assumes responsibility, accountability and leadership for the daily operations of the Complaints & Appeals Department of Sentara Health Plans (SHP), including policies, process, coordination of work, timeliness, quality and service. Performs administrative reviews ensuring that all research and documentation is complete for timely and accurate resolution of member complaints and member/provider appeals. The Manager works with the Medical Directors of the Health Plan as well as other appropriate individuals and departments to conduct investigations of customer complaints and appeals. Accountable for ensuring compliance with contractual agreements and SHP policies and procedures in addition to Federal, State and Accreditation regulations and standards. Supports and communicates Sentara Healthcare's mission, values, and goals and provides direction and oversight to departmental staff. Additional Duties Include:

Monitors trends and analyzes grievance and appeals data for submission to appropriate parties. Mentors unit and other departments for complex issues and interpretation of regulatory standards. May perform internal audits of grievance and appeals process. Hires, trains, coaches, counsels, and evaluates performance of direct reports.

Sentara Health Plans is the health insurance division of Sentara Healthcare doing business as Optima Health and Virginia Premier.

Sentara Health Plans provides health insurance coverage through a full suite of commercial products including consumer-driven, employee-owned and employer-sponsored plans, individual and family health plans, employee assistance plans and plans serving Medicare and Medicaid enrollees.

With more than 30 years' experience in the insurance business and 20 years' experience serving Medicaid populations, we offer programs to support members with chronic illnesses, customized wellness programs, and integrated clinical and behavioral health services - all to help our members improve their health.

Sentara offers an attractive array of full-time benefits to include Medical, Dental, Vision, Paid Time Off, Sick, Tuition Reimbursement, a 401k/403B , 401a, Performance Plus Bonus, Career Advancement Opportunities, Work Perks and more.

Our success is supported by a family-friendly culture that encourages community involvement and creates unlimited opportunities for development and growth.

Be a part of an excellent healthcare organization that cares about our People, Quality, Patient Safety, Service, and Integrity. Join a team that has a mission to improve health every day and a vision to be the healthcare choice of the communities that we serve!

Required Education

Bachelor's Level Degree

Experience

Required: Healthcare Complaints/Appeals - 3 years, Management - 3 years

Preferred: Health Insurance Plans - 3 years

Licenses and Certifications

None, unless noted in the "Other" section below

Skills

Required:

Preferred: None, unless noted in the "Other" section below

Keywords: Sentara Health, Chesapeake , MGR, APPEALS, Other , Chesapeake, Virginia

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