[Hiring] Manager, Complaints Grievances @UPMC

Role Description

UPMC Health Plan has an exciting opportunity for a Manager, Complaints Grievances position in the Member CGA department. This is a full time position working Monday through Friday daylight hours with rotating Saturdays that are on call. This is a remote position.

• Responsible for the tracking, trending, analysis and reporting of member complaints, member grievances, and provider complaints.
• Perform root cause analysis and initiate corrective action plans where appropriate.
• Ensure review of monitoring reports is completed timely and accurately.
• Serve as a role model of service excellence by ensuring adherence to established operational standards related to timeliness and accuracy.
• Maintain a positive attitude, meet customer commitments, and respond promptly to customer needs.
• Manage the timeliness and accuracy of complaints and grievance reporting requirements for regulatory agencies, internal executive staff, and ad hoc reports as appropriate.
• Manage activities relating to special projects for complaints and grievances.
• Ensure compliance with work plans and goals.
• Maintain an integrated process to manage complaints and grievances with other departments within the Health Plan and with external delegated entities.
• Ensure that the process, monitoring, and education process supports achievement of targeted results established by the Health Plan.
• Manage the day-to-day operations of the member complaint, member grievance, and practitioner complaint process, ensuring compliance with internal and regulatory standards.
• Ensure that second level hearings are in compliance with regulatory requirements and are performed in a professional, consistent manner.
• Represent the Health Plan on internal and external forums/committees as requested.
• Support implementation of appeals tracking system.
• Responsible for the implementation and ongoing implementation of the member grievance and appeal processes related to the Medicare products.
• Develop and monitor corrective action plans both internal and cross departmental.
• Ensure processes are compliant with external regulatory bodies, as well as NCQA standards.

Qualifications

• Bachelor's degree in business, health care, management or a related field, or equivalent relevant experience required.
• 4 years (or more) of experience in process-oriented operations, or project-oriented management.
• Managed care experience preferred.
• One (1) year of supervisory experience required.
• Experience with member and practitioner complaint/grievance processes preferred.
• Proven ability to manage processes in a health care setting with evidence of meeting established goals and outcomes.
• Strong project management skills and experience, implementing and managing cross functional projects preferred.
• Experience with managed care preferred.
• Ability to manage staff and resources within established budget to achieve desired departmental goals.
• High degree of organizational skills and problem-solving skills.
• Excellent written, verbal, and presentation skills.
• PC literacy (preferably Microsoft office products) - required.

Licensure, Certifications, and Clearances

• Licensed Registered Nurse - Preferred

Company Description

UPMC is an Equal Opportunity Employer/Disability/Veteran.