Manager, Appeals & Grievances-1

Who We Are

Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities. To learn more about who we are at Point32Health, click here.

Job Summary

Under the general direction of the Director, Appeals & Grievances, the Manager, Appeals and Grievances is responsible for the overall management of the member appeals and grievance processes for their responsible lines of business. The Manager is charged with ensuring compliance with all requirements for each state, regulatory and accreditation body. The Manager will facilitate the involvement of internal and external contributors to the process, ensuring timeliness and thoroughness of case reviews. The Manager will be responsible for the direct supervision of the department Supervisors and other key staff.

This individual will provide technical support, direction, and guidance to ensure staff deliver best in class service and resolution of Appeals and Grievances that meets and exceeds customer expectations. He/she actively leads the recommendation, development, and implementation of short and long-term quality service strategies that improve operations and member satisfaction. This individual is also responsible for departmental management, individual analyst productivity, staff development, staffing, and communication.

Key Responsibilities/Duties – what you will be doing

• Provide leadership and oversight to the complex day to day operations of the Appeals and Grievance Department
• Provide guidance and support to associates through coaching, skills development, and performance feedback to help them reach their full potential and achieve career growth. Set clear expectations for individual and team performance, regularly track progress, and implement corrective actions when necessary to ensure goals are met. Lead by example by demonstrating personal accountability and cultivate a team environment where members take ownership of their responsibilities and contribute to overall team success.
• Create and maintain effective management controls within the company's systems to monitor operational performance, productivity, and adherence to company policies.
• Continuously assess and refine processes to optimize operational efficiency, improve team performance, and maintain compliance with evolving industry standards and regulations
• Work closely with other departments to align team objectives with company-wide goals, ensuring seamless collaboration and effective communication across teams.
• Monitor quality and production standards by the interpretation of data and metrics associated with production turnaround times.
• Partner with the Appeals and Grievances Program Management Team to ensure compliance.
• Collaborate in the overall improvement in business by recommending, designing, and implementing operational changes or enhancements that improve effective and efficient delivery of Appeals and Grievances related information.
• Ensure delivery of optimal customer services by working cross functionally with internal business units and external stakeholders, including physicians, attorneys, and elected officials.
• Other duties and projects as assigned.

Qualifications – what you need to perform the job

Certification and Licensure

Education

• Required (minimum): BA/BS or equivalent experience in Appeals and Grievances
• Strongly Preferred: BA/BS in health care related field

Experience

• Required (minimum): 5-7 years of Appeals and Grievance experience
• Required: 2-3 years of prior Supervisory experience; health care benefit and regulatory knowledge; knowledge of insurance products, policies, and procedures.

Skill Requirements

• Extensive leadership experience required, including mentoring, and developing associates to support their professional growth and team success.
• A strong ethical background and deep knowledge of compliance is essential. Must have a proven ability to work closely with compliance teams and adhere to regulatory requirements.
• Demonstrated success in creating management controls through systems and reporting to ensure operational efficiency and regulatory compliance.
• Strong personal accountability and a commitment to fostering accountability within the team are essential for success in this role. You will be expected to take ownership of both individual and team performance, ensuring that goals are met and challenges are addressed proactively
• Excellent written, verbal, and presentation skills required. Ability to interact with all levels of personnel, along with knowledge of principles and practices of effective supervision.
• Effective decision-making abilities, strong communication, and organizational skills.
• Work cooperatively as a team member across multiple levels within the organization.

WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS (include special requirements, e.g., lifting, travel):

• Must be able to work under normal office conditions and work from home as required.
• Must be available to assist with mailing of member and provider documents, frequent travel will be required. This involves printing letters and dropping them off at UPS/USPS.
• Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
• Must be available to work additional hours beyond standard work schedule including weekends and holidays.
• Valid driver’s license and reliable transportation required.

The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.

Compensation & Total Rewards Overview

Commitment to Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity

​Point32Health is committed to making diversity, equity, inclusion, accessibility and health equity part of everything we do—from product design to the workforce driving that innovation. Our Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity team's strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent.  We welcome all applicants and qualified individuals, who will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

Scam Alert: Point32Health has recently become aware of job posting scams where unauthorized individuals posing as Point32Health recruiters have placed job advertisements and reached out to potential candidates. These advertisements or individuals may ask the applicant to make a payment. Point32Health would never ask an applicant to make a payment related to a job application or job offer, or to pay for workplace equipment. If you have any concerns about the legitimacy of a job posting or recruiting contact, you may contact TA_operations@point32health.org