Director, Complaints & Grievances

Profile

We offer remote work opportunities (AK, AR, AZ, CA, *CO, FL, *HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, *WA, WI & WY only).

Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position.

Veterans, Reservists, Guardsmen and military family members are encouraged to apply!

Job Summary

The Director serves as the primary contact for TriWest’s receipt, processing, resolution and reporting of routine correspondence and grievances for both TriWest’s DoD and VA contracts. Sets and maintains operational requirements which includes: addressing inquiry processing system updates, updating policies and procedures, developing core correspondence documentation/standards and implementing and updating departmental training needs. The Director is responsible for addressing operational jurisdiction on workload and partners with directors in other departments (clinical quality management, claims, provider services) on issue resolution and process improvements. Must build and maintain relationships with the departments, contractors and subcontractors that support the resolution of complaints and address disputes and delays identified in meeting contractual requirements. Ensures that reporting requirements for both programs are within contract and internal standards and lead the assessment on any standards not met in any given period. Represents the department and related workload at quality meetings (QMIC for CCN and QPIC for TRICARE) and provides executive updates to support the needs of the VP, Military & Veteran Engagement and TriWest senior leadership

Education & Experience

Required:

• Bachelor’s degree in Business, Communications or related field or equivalent work experience
• U.S. Citizenship Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation.
• Five years or more of progressively responsible management experience in health care case work processing, to include research and correspondence resolution protocols
• Current knowledge of inquiry case management programs
• Excellent verbal and written communications skills.
• Experience with claims processing, health insurance, or managed care
  
  

Preferred

Working knowledge of TRICARE and/or CCN programs, DoD and/or VA Healthcare Systems

Key Responsibilities

• Serve as the primary leader for the department’s routine correspondence and grievance processes for DoD and VA contracts.
• Oversee the design, development and updates of all complaint/routine correspondence and grievance policies and procedures for both programs. This will include designing workflows that coordinate with other customer service departments and ensuring all contractual standards and metrics are incorporated into the policies.
• Direct department’s continuous process improvement efforts on department’s casework management system (CRM), casework processing procedures and related workflows, to include engagement with other senior leadership within TriWest on collaboration initiatives.
• Ensure operational requirements of department, specific to relevant VA and DoD correspondence types, are being met, to include processing standards, reporting requirements, systems and training. Direct efforts to meet contractual requirements and serve as primary oversight and reporting representative to senior leadership and QPI when contractual standards are not met.
• Provide senior oversight on all HC and staffing matters handled by managers; support managers in handling PMP, PIP and other human capital administrative matters, as required. Direct managers in ensuring all HC and staffing matters are appropriately escalated for situational awareness.
• Represent department in communications with leadership in other TriWest departments, subcontractors, field operational offices and VA/DoD leadership to address department workload responsibilities and contractual requirements.
• Represent the department in contractually-required customer service quality meetings (QMIC/QPIC) and other corporate leadership meetings/briefings as required.
• Performs other duties as assigned.
• Regular and reliable attendance is required.
  
  

Competencies

Communication / People Skills: Ability to influence or persuade others under positive or negative circumstances; adapt to different styles; listen critically; collaborate.

Computer Literacy: Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications.

Creativity / Innovation: Ability to develop unique and novel solutions to problems; View change as necessary.

Empathy / Customer Service: Customer-focused behavior; Helping approach, including listening skills, patience, respect, and empathy for another's position.

Independent Thinking / Self-Initiative: Critical thinker with ability to focus on tasks and issues that matter most to achieving outcomes; commitment to produce outcomes without direction and to find necessary resources.

Leadership: Successfully manage different styles of employees; provide clear direction and effective coaching.

Multi-Tasking / Time Management: Prioritize and manage actions to meet changing deadlines and requirements within a high volume, high stress environment.

Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.

Problem Solving / Analysis: Ability to solve problems through systematic analysis of processes with sound judgment; has a realistic understanding of relevant issues.

Team-Building / Team Player: Influence the actions and opinions of others in a positive direction and build group commitment.

Technical Skills: Thorough understanding of TriWest's systems, policies, and procedures, correspondence processing, research and analysis skills, trend identification and documentation, editing skills

Working Conditions

Working Conditions

• Availability to work non-standard hours
• Works within a standard office environment, with moderate travel required
• Extensive computer work with long periods of sitting
  
  

Company Overview

Taking Care of Our Nation’s Heroes.

It’s Who We Are. It’s What We Do.

Do you have a passion for serving those who served?

Join the TriWest Healthcare Alliance Team! We’re On a Mission to Serve®!

Our job is to make sure that America’s heroes get connected to health care in the community.

At TriWest Healthcare Alliance, we’ve proudly been on that important mission since 1996.

DoD Statement

Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position.

Benefits

We’re more than just a health care company. We’re passionate about serving others! We believe in rewarding loyal, hard-working people who are willing to learn as they grow. TriWest Healthcare Alliance values teamwork. Join our team, fulfill your responsibilities, and you may also be considered for frequent pay raises, overtime opportunities to earn even more, recognition and reward programs, and much more. Of course, we also offer a comprehensive and progressive compensation and benefits package that includes:

• Medical, Dental and Vision Coverage
• Generous paid time off
• 401(k) Retirement Savings Plan (with matching)
• Short-term and long-term disability, basic life, and accidental death and dismemberment insurance
• Tuition reimbursement
• Paid volunteer time
  
  

*Annual base salary for Colorado, Hawaii, Washington D.C. and Washington State residents: Approx. $142,485.41 depending on experience*

Equal Employment Opportunity

TriWest Healthcare Alliance is an equal employment opportunity employer. We are proud to have an inclusive work environment and know that a diverse team is a strength that will drive our success. To that end, TriWest strives to create an inclusive environment that cultivates and supports diversity at every organizational level, including hiring and retaining a diverse workforce, and we highly encourages candidates from all backgrounds to apply. Applicants are considered for positions without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability or any other consideration made unlawful by applicable federal, state, or local laws.