*Applicants must reside in the State of Florida* *POSITION SUMMARY* Manage the formal complaints and appeals process in a timely, professional and compliant manner, to include formal member complaint resolution. Provide leadership by contributing to the development of standard operating procedures and written communication tools, coordinating external medical reviews and working with external appeal agencies, regulators and accreditation bodies. Effectively research, document, analyze and resolve appeal and complaint trends according to complex and strict rules, while identifying and communicating issues appropriately. *PRIMARY ACCOUNTABILITIES* 1. Master an understanding of laws, regulations, standards and procedures that guide formal complaint handling, and resolving formal complaints in compliance with applicable rules related to procedures and timeframes with them. 2. Correctly identify and interpret medical, contractual or legal issues related to formal complaints and communicate them to the appropriate decision-makers. 3. Prepare or oversee the preparation of routine operational reporting to identify trends in member satisfaction and compliance and identify opportunities to prevent future incorrect/inappropriate payments. 4. Conduct or oversee routine audits to ensure quality and compliance. 5. Elevate issues to senior management as necessary to minimize legal risks. 6. Identify opportunities for process improvement and reduce fraud/waste-abuse. 7. Prioritize accurate and consistent application of benefits to assure appropriate financial management of member’s policy. 8. Respond effectively to regulatory auditors regarding appeal processes. 9. Collaborate across functional areas and leaders to ensure a smooth customer experience and to resolve internal operational issues that may cause increase to member appeals/grievances volumes and drive operational efficiencies. 10. Maintain technical knowledge of claims procedures. 11. Assist in developing and implementing dispute and appeal policy and procedures. 12. Identify and report adjudication inaccuracies that are related to system configuration, benefit inconsistency and fee schedules. *LEADERSHIP ACCOUNTABILITIES*(Supervisor/Manager) 1. Define and communicate a clear, compelling vision for the team that effectively ties into the mission and vision of Health First, and inspirationally leads the team to achieve that vision. 2. Provide leadership, motivation, coaching, feedback and support to strengthen growth, development and wellness at work to build and foster effective, high performing teams. 3. Lead change through effective communication, explaining the connection and value to the organization, creating stronger buy-in and urgency, while understanding impact to the team to obtain commitment. 4. Demonstrate openness to hearing diverse ideas and thoughts; create a sense of inclusivity; and encourage collaboration across teams to help break down silos to meet the team’s and organization’s goals. 5. Recruit, select, grow, and retain highly engaged, high performing diverse and inclusive associates. 6. Demonstrate fiscal acumen and contribute to and support the strategic direction of the areas of responsibility and organization. *MINIMUM QUALIFICATIONS* • Education: Bachelor’s Degree • Licensure: None Required • Certification: None Required • Work Experience: Five years experience with health care business office or health plan • Knowledge/Skills/Abilities: * Advanced knowledge of prescription drug coverage concepts. * Advanced knowledge of health care financing and health care delivery. * Advanced knowledge of Medicare eligibility, coverage and payment provisions. * Advanced knowledge of commercial insurance provisions. * Experience working collaboratively with others to achieve goals. * Thorough understanding of regulatory requirements. * Consistent demonstration of professional behavior and commitment to quality * Demonstrated ability to communicate professionally * Demonstrated ability to work with data to identify and report trends * Highly advanced verbal and written communication skills *PREFERRED QUALIFICATIONS* • Education: No additional education required • Licensure: None • Certification: None • Work Experience: None • Knowledge/Skills/Abilities: None *PHYSICAL REQUIREMENTS*Sedentary – Office Workers • Majority of time involves sitting or standing; occasional walking, bending, stooping • Long periods of computer time or at workstation • Light work that may include lifting or moving objects up to 20 pounds with or without assistance. • May be exposed to inside environments with varied temperatures, air quality, lighting and/or low to moderate noise • Communicating with others to exchange information. • Visual acuity and hand-eye coordination to perform tasks • Workspace may vary from open to confined; on site or remote • May require travel to various facilities within and beyond county perimeter; may require use of personal vehicle **Job:** **Health First Health Plans (Health Insurance)* **Organization:** **HF Administrative Plan Inc* **Title:** *Manager Complaints, Grievances, and Appeals* **Location:** *Florida - Brevard County-Melbourne* **Requisition ID:** *075817*