Director of Appeals and Grievance

Company: Sentara Healthcare Inc
Location: Virginia Beach
Posted on: March 10, 2023

Job Description:

Optima Health is recruiting a Director of Appeals and GrevianceThis is afull-time position with dayshift hours and great benefits!Job responsibilities:

• The Director of Appeals and Grievance will plan, develop and direct the department services and activities for all existing and new business opportunities. This includes setting strategic long-term goals for Commercial, Medicaid, and Medicare business. This role assumes leadership for the program development and strategic planning of the Optima Health Appeals and Grievance Department.
• Develops policies, workflows, and compliance documents, which meet all contractual and regulatory requirements for new business product lines.
• Provide oversight for complaints, appeals and grievances reporting and analysis, and interface with Member Services on ongoing key performance indicators
• Oversee staff in their efforts to resolve and coordinate resources effectively to solve any needs for adhoc requests and ongoing projects relative to appeals and grievances, state and federal requirements
• The Director works closely with the Medical Directors to identify trends in Appeals and make recommendations to change Medical Criteria and Benefit covered items.
• Accountable for ensuring compliance with contractual agreements, SHP policies and procedures in addition to Federal, State and Accreditation regulations and standards.
• Responsible for all external audits of Appeals and Grievance: NCQA, EQRO, CMS, DMAS and BOI.Benefits: Sentara offers an attractive array of full-time benefits to include Medical, Dental, Vision, Paid Time Off, Sick, Tuition Reimbursement, a 401k/403B, 401a, Performance Plus Bonus, Career Advancement Opportunities, Work Perks, and more.Headquartered in Virginia Beach, VA, Sentara Health Plans is the health insurance division of Sentara Healthcare, offering health plans through its subsidiaries, Optima Health and Virginia Premier. Collectively, Optima Health and Virginia Premier provide health insurance coverage to over900,000 members through a full suite of commercial products including consumer-driven, employee-owned and employer-sponsored plans, individual and family health plans, employee assistance plans and plans serving Medicare and Medicaid enrollees.With more than 30 years' experience in the insurance business and 20 years' experience serving Medicaid populations, we offer programs to support members with chronic illnesses, customized wellness programs, and integrated clinical and behavioral health services - all to help our members improve their health. Wherever we serve our members, Optima Health stands out through our passion for health and service excellence.Our success is supported by a family-friendly culture that encourages community involvement and creates unlimited opportunities for development and growth.Be a part of an excellent healthcare organization that cares about our People, Quality, Patient Safety, Service, and Integrity. Join a team that has a mission to improve health every day and a vision to be the healthcare choice of the communities that we serve!To apply, please go to and use the following as your Keyword Search: JR-22270#Indeed#LI-BJ1MonsterTalroo - LeadershipThe Director of Appeals and Grievance will plan, develop and direct the department services and activities for all existing and new business opportunities. This includes setting strategic long- term goals for Commercial, Medicaid, and Medicare business. This role assumes leadership for the program development and strategic planning of the Optima Health Appeals and Grievance Department.
  -Develops policies, workflows, and compliance documents, which meet all contractual and regulatory requirements for new business product lines.
  -Provide oversight for complaints, appeals and grievances reporting and analysis, and interface with Member Services on ongoing key performance indicators
  -Oversee staff in their efforts to resolve and coordinate resources effectively to solve any needs for adhoc requests and ongoing projects relative to appeals and grievances, state and federal requirements
  -The Director works closely with the Medical Directors to identify trends in Appeals and make recommendations to change Medical Criteria and Benefit covered items.
  -Accountable for ensuring compliance with contractual agreements, SHP policies and procedures in addition to Federal, State and Accreditation regulations and standards.
  -Responsible for all external audits of Appeals and Grievance: NCQA, EQRO, CMS, DMAS and BOI.
  • Bachelor's Level Degree
    • Healthcare Complaints/Appeals 5 years
      • Time Management
      • Technology/Computer
      • Systems Evaluation
      • Systems Analysis
      • Speaking
      • Social Perceptiveness
      • Service Orientation
      • Science
      • Reading Comprehension
      • Quality Control Analysis
      • Project Management
      • Persuasion
      • Monitoring
      • Microsoft Word
      • Microsoft Excel
      • Mgmt of Staff Resources
      • Mgmt of Material Resources
      • Mgmt of Financial Resources
      • Mathematics
      • Learning Strategies
      • Leadership
      • Judgment and Decision Making
      • Critical Thinking
      • Coordination
      • Complex Problem Solving
      • Communication
      • Active Listening
      • Active Learning
      • Writing
      • Troubleshooting

Keywords: Sentara Healthcare Inc, Virginia Beach , Director of Appeals and Grievance, Executive , Virginia Beach, Virginia