Manager, Medicare Appeals & Grievances

Location: Birmingham, AL

Work Schedule: Onsite at our downtown Birmingham office throughout the training period, then transitioning to hybrid with work-from-home opportunities.

Why VIVA HEALTH?

VIVA HEALTH, part of the renowned University of Alabama at Birmingham (UAB) Health System, is a health maintenance organization providing quality, accessible health care. Our employees are a part of the communities they serve and proudly partner with members on their healthcare journeys.

VIVA HEALTH has been recognized by Centers for Medicare & Medicaid Services (CMS) as a high-performing health plan, receiving a 5 out of 5 Star rating - the highest rating a Medicare Advantage Plan can achieve and has been repeatedly ranked as one of the nation's Best Places to Work by Modern Healthcare.

Benefits

• Comprehensive Health, Vision, and Dental Coverage
• 401(k) Savings Plan with company match and immediate vesting
• Paid Time Off (PTO)
• 9 Paid Holidays annually plus a Floating Holiday to use as you choose
• Tuition Assistance
• Flexible Spending Accounts
• Healthcare Reimbursement Account
• Paid Parental Leave
• Community Service Time Off
• Life Insurance and Disability Coverage
• Employee Wellness Program
• Training and Development Programs to develop new skills and reach career goals
• Employee Assistance Program

See more about the benefits of working at Viva Health - https://www.vivahealth.com/careers/benefits

Job Description

The Manager, Medicare Appeals and Grievances oversees the daily processing of Medicare grievances and appeals for Medicare Part C and D to ensure compliance with Centers for Medicare and Medicaid Services (CMS) regulations. This includes ensuring requirements are understood by staff and incorporated into operations as well as monitoring/auditing as needed to verify compliance. This role supervises the Medicare Appeals & Grievances specialists providing training, assistance and oversight on complex cases. This position assists the department Senior Leaders with preparation for and performance on both internal and external audits.

Key Responsibilities

• Oversee the accurate and timely processing of Medicare Part C and D member appeals and grievances in accordance with the steps and timeframes required by CMS.
• Ensure on-call rotation is adequately staffed to process appeals and grievances on weekends and holidays in accordance with CMS guidelines.
• Directly supervise assigned team and handling of day-to-day employee issues. Assist department Senior Leadership with interviewing and hiring staff. Train and coach staff to perform effectively and efficiently.
• Ensure timely resolution of CTM complaints in accordance with CMS guidelines. Ensure CMS and Plan reporting is submitted in required formats and within required time frames.
• Update member notices and other materials to reflect changes in program requirements or benefits and as requested/required by regulatory agencies. Ensure prior approval of all member materials by appropriate regulatory entity.

REQUIRED QUALIFICATIONS:

• Bachelor’s degree or 5 or more years’ relevant experience in Medicare Advantage
• 5 years’ experience in managed care/health care customer service and/or appeals and grievances
• 2-4 years’ experience in a supervisory position
• Strong organizational and problem solving skills, excellent written and verbal communication skills
• Ability to manage difficult customers and complex service issues
• Ability to manage different projects concurrently within stringent deadlines
• Proficient in standard office software (Word, Excel, PowerPoint, Access)
• Sufficient information system skills to learn effective utilization of all VIVA HEALTH systems
• Ability to articulate reporting requirements and system requirements to information systems staff
• Ability to manage employees and resolve issues

PREFERRED QUALIFICATIONS:

• 3-5 years’ experience processing Medicare appeals & grievances