Supervisor Appeals and Grievances Clinical Operations

Supervisor Appeals and Grievances Clinical Operations

Location: Los Angeles, CA

Onsite Flexibility: Hybrid 1 day per month on-site, or as needed per audit

Contract Details

• Position Type: Right to Hire (Temp to Perm)
• Pay Rate: $49.12 $63.85 / Hour (USD)
• Work Authorization: Applicants must be authorized to work for ANY employer in the U.S. We are unable to sponsor or take over sponsorship of an employment Visa at this time.

Job Summary

The Supervisor of Appeals and Grievances Clinical Operations (A&G) RN is responsible for executing the day-to-day clinical operations of the A&G department, and monitoring the A&G RN staff responsibilities and activities. This includes, but is not limited to, ensuring proper staffing and coverage; monitoring and evaluating departmental operations to ensure optimal efficiency, productivity, and effectiveness; documenting and appropriately addressing excellence or deviations in work, departmental, and organizational expectations; and conducting intermittent and annual performance evaluations. This role assists in triaging identified issues/problems and forming resolutions within the scope of work/licensure. The Supervisor is a subject matter expert (SME) in Appeals & Grievances and supporting regulations, policies, protocols, and procedures. This position serves as a formal and informal instructor, and escalates issues/concerns to the appropriate person when outside of their scope.

This position is responsible for assisting with and development and maintenance of a successful and cohesive unit, with a high level of productivity and accuracy to achieve the department's overall performance metrics. The Supervisor ensures all functions of the A&G department are operating in accordance with the organization's mission, values and strategic goals, which are focused on quality care delivery and continuous improvement; and are provided in a manner that is responsive and sensitive to the needs of the client's culturally diverse membership.

The position supports the A&G Clinical Manager. This role also assists the A&G Leadership in identification of training needs including, but not limited to, collaborating in development of programs, training materials, competency checklist, and orientation checklists necessary to meet education and training needs of A&G staff. The position supervises all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports.

Key Responsibilities

• Ensure adequate/appropriate distributions of workforce, assignments and time off requests. Participate in the hiring and termination process providing recommendations with appropriate supporting documentation.
• Monitor staff's performance including productivity and compliance with regulatory requirements, compliance with policies. Identify, communicate and coach to improve staff performance. Develop tools, job aids, and workflows to optimize the process flow, performance and productivity of the A&G team. Complete intermittent and annual staff evaluations.
• Serve as the primary resource for all business-related questions/issues raised by staff; escalate to appropriate leader/team when necessary.
• Recommend and implement process improvement measures to achieve department's performance measures outcomes and goals.
• Plan and oversee A&G clinical activities according to model of care, program description and policy and procedures to provide timely, quality care and services to members.
• Maintain all assigned reporting responsibilities, conduct regular audits to ensure compliance with community, industry and organizational standards including regulatory requirements. Serve as a super-user on electronic programs and systems used by the department.
• Assist in the development of programs, workflows, tools, training materials, orientation checklists, and competency checklist necessary to meet educational needs. Train new staff, remediation of seasoned staff and cross training as needed in specified business lines.
• Serve as a leader and role model as well as technical and informational resource for staff and peers.
• Foster a culture that encourages employee contribution to ensure the department maintains an environment in which quality flourishes.
• Serve as a member/resource/liaison to the A&G Operations Team.
• Recommend resources to improve performance standards in terms of Appeals & Grievances. Collaborate with peers and colleagues within the organization to address process improvements, member's needs, department and organizational enhancements and communicate development as appropriate.
• Participate on internal and external committees as delegated or assigned.
• Serve as a consultant to other departments or organizations as needed.

Required Skills

• Knowledge of state, federal and regulatory requirements in Appeals/Care/Case/Utilization Management/Quality.
• Strong verbal and written communication skills.
• Computer literacy with proficiency in Microsoft Word, Excel, etc. and ability to learn core departmental computer systems and software.
• Excellent organizational, time management, and interpersonal skills.
• Must be detail-oriented, energetic, and an enthusiastic team player.
• Must be able to work independently.

Education Requirements

• Associate's Degree in Nursing (required)
• Bachelor's Degree in Nursing (preferred)
• Registered Nurse (RN) Active, current, and unrestricted California License (required)
• Note: Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.

Required Experience

• At least 8 years of RN acute/clinical care experience.
• At least 2 years in a lead/supervisory experience.

Nice-to-Have Experience

• Previous experience in Medicare/Medicaid in a managed care/health plan environment.

Work Environment / Physical Requirements

• Physical demand level: Light.
• This position requires work after hours, on weekends, holidays, a hybrid remote schedule, occasional flexibility in hours/shift in critical situations, and work on-call.
• This position requires handling various caseloads and flexibility to adapt to changing priorities, which may include but are not limited to redistributed work assignments, team projects, and other priorities as assigned.

Important Notes

• Must be located in California and/or willing to relocate to California upon start.
• There will be 14 A&G Specialists reporting to this position.

Benefits

• Medical, Vision, and Dental Insurance Plans
• 401k Retirement Fund

About GTT

GTT is a minority-owned staffing firm and a subsidiary of Chenega Corporation, a Native American-owned company in Alaska. We highly value diverse and inclusive workplaces and support Fortune 500 organizations across banking, financial services, technology, life sciences, biotech, utilities, and retail sectors throughout the U.S. and Canada.

Job Number: 26-11331

Industry: Healthcare