As a patient-focused organization, University of Utah Health exists to enhance the health and well-being of people through patient care, research and education. Success in this mission requires a culture of collaboration, excellence, leadership, and respect. University of Utah Health seeks staff that are committed to the values of compassion, collaboration, innovation, responsibility, diversity, integrity, quality and trust that are integral to our mission. EO/AA

• Supervise the day-to-day activities of staff who process member and provider Grievance and Appeals.
• Monitor and set goals for staff workloads.
• Ensure that staff are processing Grievances and Appeals efficiently and in compliance with applicable policies, regulations, and requirements.
• Provide education to staff and other departments on Appeals and Grievances.
• Develop process improvement initiatives, including initiatives based on appeal trends and outcomes.

Corporate Overview: University of Utah Health is an integrated academic healthcare system with five hospitals including a level 1 trauma center, eleven community health centers, over 1,600 providers, and a health plan serving over 200,000 members. University of Utah Health is nationally ranked and recognized for our academic research, quality standards and overall patient experience. In addition to our clinical delivery system, we have a School of Medicine, School of Dentistry, College of Nursing, College of Pharmacy, and College of Health providing education and training for over 1,250 providers annually. We have over 2 million patient visits annually and research grants exceeding $350 million. University of Utah Hospitals and Clinics represents our clinical operations for the larger health system.

• Lead the Appeals/Grievances program and team, monitor staff performance, attendance, schedules and other job related behavior.
• Offers regular support, feedback, counseling, and corrective action; conduct a yearly performance review.
• Develops and maintain auditing and reporting to ensure consistent application of policies and procedures.
• Maintains program policies and procedures.
• Ensures correct documentation, and safekeeping of appeals and grievances.
• Responds to program audits, as needed.
• Analyzes appeal trends, develop and implement process improvement initiatives based off of appeal trends.
• Writes and maintain program policies and procedures, ensuring the policies and procedures are compliant with applicable law.
• Develop and conduct training, both for the team and for other parts of the organization.
• Participates in other projects as required.

Knowledge / Skills / Abilities

• Ability to perform the essential functions of the job as outlined above.

• Demonstrated strong leadership skills.

• Ability to be self-motivated and work with moderate direct supervision.

• Demonstrated familiarity with local, state, and federal statutes to ensure program is operated in accordance with applicable law.

• Demonstrated understanding of insurance appeals and grievance processes.

• Demonstrated experience in improving workflows, and creating operational efficiencies.

• Demonstrated attention to detail.

• Demonstrated strong critical thinking skills.

• Demonstrated understanding of enrollment, medical coding, medical claims.

• Ability to establish good relationships with internal and external stakeholders.

• Strong verbal/written communication skills.

Qualifications

Required

• Bachelor's degree in a related field or equivalency.
• Three years of experience in a health insurance environment, preferably in managed care appeals and grievances.

Working Conditions and Physical Demands

Employee must be able to meet the following requirements with or without an accommodation.

• This is a sedentary position in an office setting that may exert up to 10 pounds and may lift, carry, push, pull or otherwise move objects while providing patient care to those with psychiatric conditions.

Carrying, Climbing, Color Determination, Crawling, Lifting, Listening, Manual Dexterity, Near Vision, Pulling and/or Pushing, Reaching, Sitting, Speaking, Standing, Stooping and Crouching, Walking