Appeals & Grievances Regulatory Program Manager

Appeals and Grievances Regulatory Program Manager

Location: Birmingham, Alabama

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 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 Appeals & Grievances Regulatory Program Manager serves as the subject matter expert on Centers for Medicare & Medicaid Services (CMS) regulatory guidance related to the Medicare Advantage Appeals & Grievances (A&G) processes as well as other federal, state, and VIVA HEALTH requirements for commercial complaints and provider appeals. This position ensures related policies and procedures are up to date based on government and company requirements and partners with the Information Systems department and software vendors to ensure supporting documentation systems are compliant.  This
individual creates and analyzes reports from appeals data for the A&G department as well as other departments in the company.

This Program Manager role is responsible for conducting quality assurance audits, plus training and coaching for Medicare, commercial, and provider appeals staff. This position will assist management with training and education for new employees and ongoing training during staff meetings and one-on-one employee meetings. This individual works closely with VIVA HEALTH’S Compliance department to ensure the accuracy of CMS audit universes and other regulatory reports and to facilitate the department’s responses in regulatory audits. The role is responsible for communicating any regulatory updates or changes to VIVA HEALTH’S A&G team.

Key Responsibilities

• Maintains current knowledge of CMS and other regulatory and sub-regulatory guidance related to areas of responsibility and interpret/communicate impact on work processes to stakeholders. Ensures work activities within A&G align with CMS and other regulatory requirements.
• Creates and verifies the accuracy of reports for CMS and to meet other regulatory requirements as well as VIVA HEALTH’S internal requirements. Analyzes data to provide actionable information related to A&G and provide feedback to management when opportunities for improvement are identified.
• Serves as the A&G systems subject matter expert and point of contact between VIVA HEALTH and system vendor(s). Maintains supporting workflow system for maximum efficiency and in compliance with regulatory updates by providing written change specifications to the vendor and Information Systems department.
• Collaborates on system updates and conducts user acceptance training as needed. Creates and manages Jira tickets related to maintenance of workflow system.
• Provides and/or coordinates training for new employees in the department on the workflow system. Trains and coaches current employees to ensure job duties are performed efficiently through the system and in accordance with policies and procedures.
• Prepares and maintains policies and procedures and training documents related to Medicare, commercial, and provider A&Gs under the guidance of department management.  Ensures staff has access to current policies, procedures and guidelines to effectively perform essential job functions.
• Serves as a subject matter expert to the Compliance Officer and regulatory auditors related to A&G.
• Assists with the development, maintenance, and coordination of the department’s quality assurance program, compliance, and process improvement initiatives.
• Informs and educates A&G team of findings, recommendations, and corrections. Works collaboratively with department management to provide A&G team ongoing feedback. Validates the integrity, accuracy, and appropriateness of all complaints, appeals, grievances, and disputes processed within the department.

REQUIRED QUALIFICATIONS:

• Bachelor's Degree
• At least 3-5 years in regulatory guidance, compliance, or related field
• Experience working with workflow systems/databases and generating and analyzing reports using Excel and other tools
• Ability to design reports and implement oversight activities to measure employee accuracy and adherence to department processes
• Ability to learn complex processes and systems
• Ability to read and interpret regulations and other guidance
• Able to provide constructive feedback in a clear, concise, and respectful manner
• Demonstrate excellent oral and written communication skills including the ability to provide feedback to department employees to drive performance improvement
• Highly motivated, goal oriented, and willing to work to satisfy department goals when required
• Highly proficient in the Microsoft Office suite of products including Excel, Word, and PowerPoint
• Ability to be flexible and accommodate shifting priorities
• Ability to perform day-to-day responsibilities with minimal supervision, exercising independent judgment and maintaining confidentiality
• Excellent organizational and time management skills

PREFERRED QUALIFICATIONS:

• Advanced Graduate Degree in a health care related field, business, or law
• 3 years’ experience in Medicare Advantage A&G
• Experience with project management and Jira or similar issue tracking system
• Experience interpreting governmental regulations and applying them to business operations
• Experience in a liaison role between a business unit and information technology services and compliance
• Experience in technical writing including policy and procedures
• Experience in an auditing or quality assurance role