Manager, Clinical Appeals

Please email hr_business_partners@bcbsri.org if you are a candidate seeking a reasonable accommodation for the application and/or interview process.
Location: Hybrid
Compensation: $80,100 - $120,200
Jump into the new world of health insurance:
At Blue Cross & Blue Shield of Rhode Island (BCBSRI), our business is healthcare. But our focus is on improving lives. Be part of a team that is large enough to make a difference but small enough to be innovative. Work in a rapidly changing field. Take a chance to be creative. Move outside the status quo. Shape new ideas with the power of a national brand behind you.
Join others who know diversity is strength:
We appreciate and celebrate everything that makes us unique: age, national origin, citizenship status, perspectives, experiences, physical or mental disability, military status, race, ethnicity, religion, gender, sexual orientation, gender identity and/or expression. Our diversity strengthens us as an organization and helps us better serve an increasingly diverse Rhode Island population.
Why this job matters:
Manage the daily work of administrative grievance and appeals staff to ensure adherence to quality standards, deadlines, and proper procedures. Ensure operations are consistent with state and federal guidelines for all products, including Centers for Medicare and Medicaid Services (CMS), RI Department of Health (DOH), US Department of Labor (DOL), Patient Protection & Affordable Care Act and NCQA and Blue Cross Blue Shield Association requirements. Provide performance management oversight and employee development. Manage workflow of department; implement corporate or departmental policies, procedures, and service standards.
What you will do:

• Coordinate the workflow and operations of two units within the grievance and appeals department, commercial and Government Programs. Provide direction and guidance to staff. Review and evaluate work and prepare performance reviews.
• Collaborate with management to assist with the oversight and coordination of the research, negotiation, and resolution of member and provider complaints, grievances and appeals for all products.
• Ensure adherence to regulatory, accreditation, BCBS Association and corporate timelines and quality standards.
• Conduct research on standards of practice, policy, and procedures; provide recommendations to management to improve processes.
• Act as a resource for all audits of grievances and appeals, both external and internal in nature, i.e. CMS, DOH, Internal Audit, Compliance, etc.
• Work with the staff to create/update corporate Policies and Procedures and departmental workflows as required. Train staff as needed.
• Oversee senior management and regulatory cases as well as escalated issues. Provide guidance to staff on complex cases.
• Represent the department on corporate committees and cross-functional workgroups.
• Perform other duties as assigned.

What you need to succeed:

• Unrestricted Rhode Island Nursing License
• Five to seven years of experience in managed care or health plan operations
• Three to five years of management experience or experience leading a team
• Demonstrated experience in timely processing of complaints and appeals

Extras:

• Knowledge of grievance and appeals processes
• Knowledge of health insurance laws and regulations and ability to interpret regulatory requirements and translate into business requirements
• Ability to set and maintain quality standards
• Ability to develop and maintain effective and collaborative working relationships
• Strong and effective decision-making skills
• Strong organizational and time management skills
• Proficiency with Microsoft Suite of products (i.e., Word, Excel, PPT, etc.)
• Ability to interpret and understand federal and state health insurance regulations
• Ability to perform root cause analysis
• Ability to create and monitor corrective action plans
• Advanced analytical skills, with the ability to interpret and synthesize complex data sets
• Excellent verbal and written communications skills
• Negotiation skills
• Presentation skills

Location:
BCBSRI is headquartered in downtown Providence, conveniently located near the train station and bus terminal. We actively support associate well-being and work/life balance and offer the following schedules, based on role:

• In-office: onsite 5 days per week
• Hybrid: onsite 2-4 days per week
• Remote: onsite 0-1 days per week. Permitted to reside in the following states, pending approval from the Human Resources Department: Arizona, Connecticut, Florida, Georgia, Louisiana, Massachusetts, North Carolina, Oklahoma, Rhode Island, South Carolina, Texas, Virginia

At Blue Cross & Blue Shield of Rhode Island (BCBSRI), diversity and inclusion are central to our core values and strengthen our ability to meet the challenges of today's healthcare industry. BCBSRI is an equal opportunity, affirmative action employer. We provide equal opportunities without regard to race, color, religion, gender, age, national origin, disability, veteran status, sexual orientation, genetic information and gender identity or expression.
The law requires an employer to post notices describing the Federal laws prohibiting job discrimination based on race, color, sex, national origin, religion, age, equal pay, disability, veteran status, sexual orientation, and genetic information and gender identity or expression. Please visit https://www.eeoc.gov/employers/eeo-law-poster to view the "EEO is the Law" poster.

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