Lumeris Manager, Grievances in St. Louis, Missouri

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Position:

Manager, Grievances

Position Summary:

The Manager, Grievances is accountable for the operation of intake and timely resolution of grievances for the Essence Health Care and other Lumeris payer and provider-based health plan customers. The Manager, Grievances oversees department initiatives to ensure efficiencies of the grievances end-to-end process. The position will be responsible for partnering with internal stakeholders to facilitate practices to optimize effectiveness, increase scalability, and uncover gaps while limiting compliance risk.

Job Description:

  • Ensure the completion of all grievances are processed within Centers for Medicare and Medicaid Services (CMS) guidelines and other contractual obligations

  • Monitor grievances and report escalations to senior management and internal business partners

  • Ensure that all members and provider grievances are processed and investigated according to CMS guidelines and contractual requirements

  • Lead and ensure timely and thorough responses to all grievances

  • Oversee research, investigation, negotiation and resolution of all types of grievances

  • Prepare team, advise and collaborate with Director, Healthcare Quality to ensure necessary roles, people, processes and technology are present to easily pass audits by CMS or third-party assessor

  • Build, mentor and coach the Grievances team in order to drive business objectives

  • Plan, organize, and direct the daily and weekly work activity of the Grievances team

  • Rapidly develop and maintain a thorough and up-to-date understanding of the CMS requirements for all aspects of Health Plan Grievances

  • Assess, collaborate to revise (as necessary), and maintain all Grievances policies and procedures

  • Contribute as a value-add, active member of cross-functional committees/teams/work groups as directed by Director and VP of Quality Improvement

  • Perform root cause analysis on grievances considered “untimely” to identify the gap and develop an action plan to alleviate future issues

  • Collaborate with the Central Audit Team and provide subject matter expertise regarding all CMS and other 3rd party audits

  • Collaborate with project implementation teams regarding onboarding of new clients

  • Support NCQA accreditation as the business owner for Grievances

  • Accountable for all activities related to reporting, management, and continuous improvement of plan level and IRE overturn processes and individually overturned cases

  • Drives personal and team accountability for all work related to the grievances process

Experience, Qualifications, and Education:

  • Registered Nurse with an unrestricted license in any state. Ability to obtain an unrestricted license in Missouri within 180 days

  • 8+ years of professional work experience with a minimum of 5+ years of experience working as a Registered Nurse

  • Demonstrated progressive leadership experience

  • Demonstrated experience working in a managed care environment

  • Working knowledge of the Grievances and/or Utilization Management process

  • Strong written and verbal communication skills

  • Demonstrated experience building a team including effective hiring of new employees and development of current staff

  • Experience building a culture of continuous learning and driving subject matter expertise within the team by utilizing cross-training and team learning activities

  • Ability to prioritize work in a fast-paced environment with competing priorities

  • Experience building a culture of accountability and ownership within a team

  • Must be a self-starter who can balance working collaboratively and autonomously as required

Lumeris is an EEO/AA employer M/F/V/D.

Location:

St. Louis, MO

Time Type:

Full time

Status:

XL - FT

Join Our Growing Team!

Lumeris serves as a long-term operating partner for organizations that are committed to the transition from volume- to value-based care and delivering extraordinary clinical and financial outcomes. Lumeris enables clients to profitably achieve greater results through proven playbooks based on collaboration, transparent data and innovative engagement methodologies. Lumeris offers comprehensive services for managing all types of populations, including launching new Medicare Advantage Health Plans, Commercial and Government Health Plan Optimization, and Multi-Payer, Multi-Population Health Services Organizations (PHSOs). Currently, Lumeris is engaged with health systems, provider alliances and payers representing tens of millions of lives moving to value-based care.

Over the past seven years, we have tripled in size to more than 800 employees and built the only solution on the market with our proven outcomes. For the past six years, Essence Healthcare, a long-standing Lumeris client, has received 4.5 Stars or higher from the Centers for Medicare and Medicaid Services (CMS). Essence Healthcare was Lumeris’ pioneer client and has been leveraging Lumeris for more than a decade to operate its Medicare Advantage plans, which serve more than 60,000 Medicare beneficiaries in various counties throughout Missouri and southern Illinois.

In 2018, Lumeris was named Best in KLAS for Value-Based Care Managed Services in the area of client-reported impact on the Triple Aim by KLAS Research. This was the third year in a row Lumeris received the award, and it has only been given for three years. As the industry’s most reliable and effective partner for developing population health management solutions, our success is driving tremendous growth in our company. Join us today in making a real difference in how healthcare is delivered!

Why Join Lumeris?

At Lumeris, you will be part of team that is focused on solving the nation’s healthcare problem, and you will be able to contribute to our purpose. Our environment is fast-paced, change-oriented and focused on growth and employee engagement. At Lumeris, we know that talent is best utilized when given the opportunity to succeed. That is why we have removed the boundaries that inhibit success and focus on fostering an environment that allows employees to utilize their talents.