Who We Are:

Founded in 2016, we’ve become a trusted and valued partner for health plans and providers. We offer a modern integrated ecosystem of healthcare operations, processes, and products, with inherent scalability, efficiency, and predictable outcomes. Our BPaaS delivery solutions work behind the scenes to manage our customers’ complex admin operations, giving them elbow room to focus on their members’ needs and well-being.

Bending cost curves, guaranteeing outcomes, finding paths through roadblocks – that’s our way of life. Our customers count on us to safely navigate them through deadlocks. We have a strong global presence and a dedicated workforce of 4000+ people spread across the world.

Our brand is built on strong foundations of simplicity, honesty, and leadership, and we stay inspired in our goal to unburden healthcare and ensure it reaches all, equitably and effectively.

You Are:

The Appeals and Grievance Director is responsible for managing a large A&G team encompassing multiple clients as well as the overall compliant processing of Appeals and Grievance cases.  The director is responsible for all Service Level Agreement achievement and will implement training, identify continuous improvement opportunities, apply technology, and ensure that audit activities are conducted. The Appeals and Grievance Director will manage staff to ensure that cases are assigned and documented in the highest quality possible and conduct tracking and trending activities to ensure identified issues are communicated to the appropriate business clients. The director will be educated on all regulatory needs and adhere to all compliance.

The Opportunity:

·        The Appeals and Grievance Director demonstrates an excellent working knowledge of Appeals and Grievance regulations and CMS guidance and the ability to convey working knowledge to A&G Analysts. 

·        Follows Grievances and Appeals processes and systems to ensure data to support quality, production, and financial goals. Performs Appeals and Grievance process oversight activities.

·        Ensures development and updates of Desk Level Procedures and enforces continuous training to A&G Analysts. Mentors new and existing A&G Analysts and leaders.

·        Investigates and thoroughly documents trends for grievances and appeals as needed.

·        Drives production of QA reports to conduct prospective auditing.

·        Works with Operations to determine valid processing errors and root cause analysis and used that feedback to reeducate A&G Analyst.

·        Conducts post case closing analysts to ensure case meets all CMS Universe requirements.

·        Ensures all A&G SLAs are met and that A&G cases are processed timely.

·        Develops proactive strategies to train A&G analysts on how to properly manage individual inventory.

·        Coordinates appropriate reviewer assignments for Appeals and Grievance cases.

·        Responsible for ensuring Appeals and Grievances move through each review level to ensure timely completion.

·        Drives operational excellence into all processes and departmental interactions.

·        Brings to management’s attention any system or process issues and drive those solutions.

·        Coordinates effectively with the Information technology department and vendors on upgrades, fixes, and system changes. 

 

What you need:

·        Bachelor’s degree in business administration, Economics, Health Care, Information Systems, Statistics, or another related field is required. Master’s Degree in related field preferred. Certification or progress toward certification is highly preferred and encouraged

·        At least 10 years’ experience in a supervisory or management role. Experience in healthcare or insurance industry is considered a plus. 

·        Experience in leading projects, coordinating efforts that involve other people, demonstrated leadership skills and the ability to speak effectively before groups of customers or employees.

·        At least 5 years’ experience in a grievance and appeals environment including experience with the grievance and appeals regulations per CMS. Experience with CMS regulations regarding Medicare Advantage, and Medicare Advantage plans appeals and grievance processes.

·        Experience in medical benefits and health care industry regulations and processes; experience in claims, authorizations, working in or with Medicare Advantage plans, or Independent Review Entities.

·        Ability to read and interpret documents such as Statements of Work, Regulations, productivity reports.

·        Experience in legal research and monitoring of federal and state regulatory laws and legislations preferred.

·        Strong analytical, organizational, planning and problem-solving skills.

·        Ability to work in a high paced environment with strong focus and drive to serve the customer.

·        Demonstrated track record of generating results and having an impact on organizations.

 

Compensation can differ depending on factors including but not limited to the specific location, role, skill set, education, and level of experience. As required by applicable law, UST HealthProof provides a reasonable range of compensation for roles that may be hired in various U.S. markets as set forth below.

Role Location: Remote US

Compensation Range: $175,000 - $195,000

Benefits

Full-time, regular employees accrue up to 16 days of paid vacation per year, receive 6 days of paid sick leave each year (pro-rated for new hires throughout the year), 10 paid holidays, and are eligible for paid bereavement leave. They are eligible to participate in the Company’s 401(k) Retirement Plan with employer matching. They and their dependents residing in the US are eligible for medical, dental, and vision insurance, as well as the following Company-paid benefits: basic life insurance, accidental death and disability insurance, and short- and long-term disability benefits. Regular employees may purchase additional voluntary short-term disability benefits, and participate in a Health Savings Account (HSA) as well as a Flexible Spending Account (FSA) for healthcare, dependent child care, and/or commuting expenses. Certain regular employees may have the potential for quarterly incentive-based bonuses and or commissions depending on role. Benefits offerings vary in Puerto Rico. Part-time employees receive 6 days of paid sick leave each year (pro-rated for new hires throughout the year) and are eligible to participate in the Company’s 401(k) Retirement Plan with employer matching. Full-time temporary employees receive 6 days of paid sick leave each year (pro-rated for new hires throughout the year) and are eligible to participate in the Company’s 401(k) program with employer matching. They and their dependents residing in the US are eligible for medical, dental, and vision insurance. Part-time temporary employees receive 6 days of paid sick leave each year (pro-rated for new hires throughout the year). All US employees who work in a state or locality with more generous paid sick leave benefits than specified here will receive the benefit of those sick leave laws.

What We Believe 

 At UST HealthProof, we envision a bold future for American healthcare. Our values are the bedrock beliefs our organization holds dear. They not only define what our brand stands for but also serve as a compass guiding every action and decision.

 Guiding Principles

 These principles illuminate the path of ‘how’ we operate. They detail actions and behaviors we much embody to honor our values and achieve our goals.

 ·        Simplicity Simplifying complexity underlines everything we do—this approach is what makes us unique. We come with an open mind and straightforward approach, cutting our way to the core with measurable and actionable insights.

  ·        Integrity Integrity is our currency to build relationships. We believe in being open and honest. It is only natural when we have nothing to hide. It demonstrates that we are here to do the right thing, no matter who is watching.

·        People-Centricity Everything that we do reflects our deep bonds with peers and customers. These aren't mere transactions, but transformational ties. They shape our culture and decisions, affirming that our true value lies in the lives we touch and impact.

 ·        Leadership Taking ownership is about taking initiative, being in-charge and driving things to completion. It’s a brave choice to ‘own’ all aspects of our work, ensuring we take full responsibility for everything we handle.

 Mission

A future possible only when health plans are free from administrative burdens so they can truly focus on what matters more – their members’ well-being. 

Equal Employment Opportunity Statement
UST HealthProof is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other applicable characteristics protected by law. We will consider qualified applicants with arrest or conviction records in accordance with state and local laws and “fair chance” ordinances. UST HealthProof reserves the right to periodically redefine your roles and responsibilities based on the requirements of the organization and/or your performance.

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