Supervisor, Appeals & Grievances Operations

“Pay scale information is not necessarily reflective of actual compensation that may be earned, nor a promise of any specific pay for any selected candidate or employee, which is always dependent on actual experience, education, qualifications, and other factors.  A full review of our comprehensive pay and benefits will be discussed at the offer stage with the selected candidate.”

This position is not eligible for Sponsorship.

MedImpact Healthcare Systems, Inc. is looking for extraordinary people to join our team!

Why join MedImpact? Because our success is dependent on you; innovative professionals with top notch skills who thrive on opportunity, high performance, and teamwork. We look for individuals who want to work on a team that cares about making a difference in the value of healthcare.

At MedImpact, we deliver leading edge pharmaceutical and technology related solutions that dramatically improve the value of health care. We provide superior outcomes to those we serve through innovative products, systems, and services that provide transparency and promote choice in decision making. Our vision is to set the standard in providing solutions that optimize satisfaction, service, cost, and quality in the healthcare industry. We are the premier Pharmacy Benefits Management solution!

Essential Duties and Responsibilities include the following. Other duties may be assigned.

• The Supervisor oversees A&G team coordinators assigned to their team. The A&G Coordinators receive requests for Appeals and Grievances and perform a triage function to determine whether all aspects of the case are being addressed. This includes obtaining history related to previous prior authorizations or appeals and categorizing the current request appropriately. The process may involve telephone contact with prescribers' office staff, other MedImpact departments such as Customer Service, and the member or the member’s appointed representative. These calls must be conducted in a tactful, efficient, and productive manner while maintaining all safeguards regarding the protection of sensitive, privileged information. The team is expected to deliver timely, accurate results that meet A&G turnaround times and client specifications. The Supervisor ensures that staff is properly trained and supervised to execute processing tasks accurately and within required timelines, in compliance with performance standards and regulatory requirements.

• Performs frontline supervision, including interviewing and recommending candidates for hire, training and developing team members, assigning and monitoring work in progress, evaluating performance, enforcing attendance and performance standards, administering employee corrective action, and making compensation recommendations. Models and cultivates staff behaviors that achieve business success, including leadership skills, collaboration, accountability, and ownership. Ensures that staff members are aware of business plan objectives, individual accountabilities, and the competencies critical to successful job performance.

• Supervises the assigned work group to achieve service commitments, including sustainable, measurable, accurate, reliable, and timely execution of service deliverables. Provides day-to-day leadership by developing and administering policies, business processes, quality standards, and performance measurement criteria. Sets high standards and encourages new ideas for improving organizational performance.Partners with other MedImpact teams to effectively resolve customer issues and inquiries, implement new business, and design solutions that meet the mutual needs of MedImpact and its customers. Participates as a member of cross-functional workgroups, teams, and committees as assigned. Partners with the A&G Manager and internal teams to develop policies and procedures that maintain compliance with NCQA standards and applicable state and federal legislation and regulations. Assists with administration of the Utilization Management Oversight Committee (UMOC).

• Participates in the design and implementation of appeal and other required programs for new and existing clients, including design and development of standard and customized processes.  Helps to maintain ongoing client interaction for key clients regarding appeal program assessment and improvement.

• Assists with regularly scheduled individual and departmental meetings that will cover training and operational issues for Appeal Clinical Reviews and Quality Improvement.  Oversees the continuing development of clinical staff and recommend appropriate training modules.  Works to operationalize the distance-learning program and the scheduling and monitoring of new coordinator onboarding.

• Collaborates with Prior Authorization teams, Customer Service, Benefits and Pharmacy Network operational management staff as well Clinical Consultative Services (CPM Team) and participates in cross-functional meetings as necessary.

• Provides feedback to the A&G Supervisor, Appeal Clinical Programs, and Lead Coordinator regarding the processing of appeal cases referred for clinical review. Provides in-service education to Appeal Clinical Specialist, A&G Coordinates and as requested by the A&G Manager or Medical Director

Supervisory Responsibilities        

Manages assigned staff in the segment area. Responsible for the overall direction, coordination, and evaluation of the unit. Carries out supervisory responsibilities in accordance with the organization's policies and applicable laws. Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems. Supports and enforces all company policies and procedures in a fair and consistent manner, taking corrective action whenever necessary.

Client Responsibilities

This is an internal and external client facing position that requires excellent customer service skills and interpersonal communication skills (listening/verbal/written).  One must be able to; manage difficult or emotional client situations; Respond promptly to client needs; Solicit client feedback to improve service; Respond to requests for service and assistance from clients; Meet commitments to clients.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience

BS/BA Degree or equivalent; 2+ years of experience (or equivalent combination of education and experience) and 1 year of supervisory experience.  Supervisory experience may be substituted with two (2) years of MedImpact experience plus an appropriate external leadership training program and internal mentorship with a seasoned leader at the Director level or above that must be completed within 12 months in new position.

Computer Skills

Proficiency with MS Windows Office programs, including MS Word, Excel, and Outlook to create complex documents, manage schedules, and analyze data. 

Certificates, Licenses, Registrations

Must successfully complete one of the national certification exams OR obtain state licensure (in an U.S. State or Territory). Maintains a current Pharmacy Technician License and/or CPhT certification without restriction.

Other Skills and Abilities

• Familiarity with medical record confidentiality processes and procedures, such as HIPAA training.  Excellent skills in written and oral communication; organization/prioritization; decision-making; problem analysis and resolution; negotiation; team building; and leadership. Ability to maintain a high degree of confidentiality using, tact, discretion, and professionalism in all aspects of the job.  Strong attention to detail and follow-through skills.

Reasoning Ability

• Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.

• Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

Mathematical Skills  

• Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.

Language Skills

• Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. 

• Ability to write routine reports and correspondence.  Ability to speak effectively before groups of customers or employees of organization.

Competencies To perform the job successfully, an individual should demonstrate the following competencies:

Building Effective Teams

Decision Quality

Informing

Confronting Direct Reports

Delegation

Organizational Agility

Customer Focus

Drive for Results

Political Savvy

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this Job, the employee is regularly required to sit and talk or hear. The employee is regularly required to stand; walk; use hands to finger, handle, or feel and reach with hands and arms. The employee must occasionally lift and/or move up to 25 pounds.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

This position may regularly be exposed to or encounter moving mechanical parts, high, precarious places, fumes or airborne particles, toxic or caustic chemicals, outdoor weather conditions, risk of electrical shock or vibration. The noise level in the work environment is usually moderate (examples: business office with computers and printers, light traffic).

Work Location

This position works on-site at the San Diego Headquarters or other company location (or from a remote location with management approval based on business requirements). Must provide adequate support to internal clients; be available for regular interactions and coordination of work with other employees, colleagues, clients, or vendors; as well as be available to facilitate effective decisions through collaboration with stakeholders.

Working Hours

This is an exempt level position requiring the incumbent to work the hours required to fully accomplish job responsibilities and reasonable meet deadlines for work deliverables. The individual must have the flexibility to work beyond traditional hours and be able to work nights, weekends or on holidays as required.  Work hours may be changed from time to time to meet the needs of the business.  Typical core business hours are Monday through Friday from 8:00am to 5:00pm.

Travel

This position requires no travel however attendance maybe required at various local conferences and meetings.

• Medical / Dental / Vision / Wellness Programs
• Paid Time Off / Company Paid Holidays
• Incentive Compensation
• 401K with Company match
• Life and Disability Insurance
• Tuition Reimbursement
• Employee Referral Bonus

To explore all that MedImpact has to offer, and the greatness you can bring to our teams, please submit your resume to www.medimpact.com/careers

MedImpact, is a privately-held pharmacy benefit manager (PBM) headquartered in San Diego,
California. Our solutions and services positively influence healthcare outcomes and expenditures, improving the position of our clients in the market. MedImpact offers high-value solutions to payers, providers and consumers of healthcare in the U.S. and foreign markets.

To perform this job successfully, the successful candidate must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and/or ability required.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The above
statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified.