Manager, Appeals & Grievances

At Blue Cross and Blue Shield of Minnesota we are committed to paving the way for everyone to achieve their healthiest life. We are looking for dedicated and motivated individuals who share our vision of transforming healthcare. As a Blue Cross associate you are joining a culture that is built on values of succeeding together finding a better way and doing the right thing. If you are ready to make a difference join us.

In this positions you will develop implement continuously monitor and improve processes and programs to reduce appeals and grievance inventory while providing guidance support and solutions for team(s) on a breath of this position it will require client-facing problem solving analytical continuous improvement change management and execution skills. You will serve as an expert resource for complex issues interpretation of regulatory standards and both internal and external audits. You will be accountable for the daily activities of the department and own the escalated corporate appeal process to meet objectives of timeliness thoroughness consistency and compliance requirements. You will identify and evaluates appeal trends and implement strategies and tactics to assist in shaping future efforts.

In this position you will be responsible for leading and overseeing projects and initiatives that impact appeals and grievances. Serves as a lead role in corporate and mandated initiatives this position drives changes effectively communicates develops business rules enforces regulatory requirements and regulates workflow processes to ensure systems and support are in place for proper appeals handling.

• Identifies and evaluates appeal trends and implements strategies and tactics to assist in shaping future efforts while ensuring we remain in compliance with department objectives and regulatory and compliance requirements.
• Owns the escalated corporate appeal process (pre and post review) for the Corporate Appeals Committee. This includes but is not limited to legal medical professionals senior leaders and includes external legal counsel and providers.
• Lead and/or provide business ownership and subject matter expertise for internal workgroups/committees in support of core and strategic projects that affect business workflow requirements and vendor relationships including processes and rules.
• Participates in the evaluation selection and drives implementation of new technical solutions to increase the efficiency and new capabilities within the team.
• Serve as a change agent by championing organizational initiatives leading teams through change and fostering a culture of adaptability continuous improvement and innovation.

• Lead transformational change by identifying analyzing and implementing solutions for potential pain points through continuous improvement activities in order to improve the associate and member/provider experience.
• Analyze appeals operational reporting and communicates trend analysis and opportunities for process improvements to senior leadership and business partners at all levels.
• Establish and maintain a positive collaborative working relationship with enterprise business partners including but not limited to Customer Service Care Management Claims Compliance and Network Management to ensure processes are streamlined and efficient.
• Work strategically with new and existing vendors to ensure appeals processes continue to remain compliant with regulatory requirements and to ensure opportunities are capitalized on and the effects of competitive activity are minimized relative to brand message and position.
• Partner directly with compliance teams and other internal audit teams to ensure that new regulatory requirements are implemented and the appeals team members continue to maintain audit readiness.
• Provide strategic direction to all associates for questions regarding processes projects and/or data.
• Manage the allocation of resources including staff and technology to meet corporate objectives and regulatory/contractual requirements for handling appeals to ensure compliance with state federal and accreditation requirements.
• Conducts performance evaluation and is responsible for managing employees including skill and career development policy administration coaching on performance management and behavior employee relations and cost control.
• Identify and execute staff training plans including the development of training modules/materials.
• Performs additional responsibilities consistent with the scope and level of the role as assigned.

• 5 years of progressive customer service/operations experience with 1 staff team lead or project lead experience.
• Bachelors degree; in lieu of a degree an additional two years of relevant experience beyond the qualifications listed above may be accepted.

• Masters degree in related field.
• Ability to communicate expectations and priorities clearly to team members actively listen to resolve issues and remove barriers and drive alignment across teams and stakeholders.
• Ability to analyze department challenges guide team decision-making and collaborate across teams to drive resolution and next steps.
• Ability to effectively organize team work balance priorities across projects and manage time and resources to ensure timely delivery and coordination.
• Knowledge of state and/or federal regulatory policies and/or provider agreements and a variety of health plan products.
• Experience with Medicare Medicaid service and issue resolution.
• Knowledge of Health Plan operations including claims enrollment sales and marketing health services and membership.

Hybrid

Role designation definition:

• Teleworking is working full time remote.
• Hybrid is a minimum of 2 days onsite.
• Onsite is full-time onsite.

Anchored in Connection

Our hybrid approach is designed to balance flexibility with meaningful in-person connection and collaboration. We come together in the office two days each week most teams designate at least one anchor day to ensure team interaction. These in-person moments foster relationships creativity and alignment. The rest of the week you are empowered to work remote.

$102400.00 - $138300.00 - $174200.00 Annual

Pay is based on several factors which vary based on position including skills ability and knowledge the selected individual is bringing to the specific job.

We offer a comprehensive benefits package which may include:

• Medical dental and vision insurance

• Life insurance

• 401k

• Paid Time Off (PTO)

• Volunteer Paid Time Off (VPTO)

• And more

To discover more about what we have to offer please review our benefits page.

At Blue Cross and Blue Shield of Minnesota we are committed to paving the way for everyone to achieve their healthiest life. Blue Cross of Minnesota is an Equal Opportunity Employer and maintains an Affirmative Action plan as required by Minnesota law applicable to state contractors. All qualified applications will receive consideration for employment without regard to and will not be discriminated against based on any legally protected characteristic.

Individuals with a disability who need a reasonable accommodation in order to apply please contact us at:

Blue Cross and Blue Shield of Minnesota and Blue Plus are nonprofit independent licensees of the Blue Cross and Blue Shield Association.

Physical requirements.