Job Title Director Grievance and Appeals
Location Rancho Cucamonga, CA
Job Description Morgan Consulting Resources, Inc. has been retained to conduct the search for the Director of Grievance and Appeals for Inland Empire Health Plan. This position is located in Rancho Cucamonga, CA.

About the organization:

Inland Empire Health Plan (IEHP) is one of the largest not-for-profit health plans in California. They serve over 1.2 million members in Riverside and San Bernardino counties through government sponsored programs including Medi-Cal (California’s Medicaid Plan) and the Cal MediConnect Plan (Medicare-Medicaid Plan).


IEHP’s mission is to organize and improve the delivery of quality, accessible and wellness based healthcare services for their community. Their core values include:
  • Health and Quality before Costs: they believe in placing members’ health care needs above all else.
  • Team Culture: they are a dedicated and cohesive team focused on member care and supporting their providers.
  • Think and Work LEAN: they strive to continuously improve their daily operations and delivery of healthcare services.
  • Partner with Providers: they recognize the necessity of a strong working relationship with their providers – based on mutual respect and collaboration.
  • Stewardship of Public Funds: they are accountable to the public and strive for transparency and prudent fiscal management.

For more information about the organization, please visit: https://ww3.iehp.org/.

About the Director of Grievance and Appeals:

Reporting to the Executive Director of Health Services Operations, the Director of Grievance and Appeals will oversee a staff of 95 with the following direct reports: three managers and seven supervisors. We are looking for a Director with strong grievance and appeals experience and the ability to foster collaborative relationships vertically and horizontally across the organization. Additionally, candidates who have a strong focus on mission/values are ideal for this position.


The Director will lead the department in meeting turnaround metrics and interfacing with CMS on audits. He or she will be involved in issue identification and resolution. Medi-Cal experience highly preferred.

Major goals and projects:

  1. Implementation of State audit findings in the department;
  2. Manage the “All Plan Letters” as outlined by the State;
  3. Prepare for anticipated CMS audit early 2019.
Minimum qualifications:

Education/Licensure:
  • Possession of a valid clinical license issued by the State of California required. Clinical licensure requirement can be met via: Physician Assistant (PA, PA-C), Nurse Practitioner (NP), Family Nurse Practitioner (FNP), Adult Nurse Practitioner (ANP), Pharmacist (PharmD), or Registered Nurse (RN).
  • Bachelor’s degree in a health-related field from an accredited four-year institution preferred.
  • Valid State of California driver’s license.

Experience, Knowledge, Skills and Abilities:

  • A minimum of two years’ experience leading healthcare utilization management or care management teams required.
  • Four or more years’ experience in quality assurance, utilization management, case management, and/or provider liaison duties, preferably in an HMO or Managed Care setting.
  • Two or more years’ experience working in a clinical setting required.
  • Strong knowledge of State of California and Federal grievance and appeal regulations.
  • Excellent written and verbal communication skills that adapt to targeted audience.
  • Strong team leadership skills.
  • Ability to demonstrate critical thinking, strong problem solving capability.
  • Strong attention to detail.
  • Positive attitude and ability to develop teams that are productive, adaptive and collaborative.

If someone you know has the qualifications we seek, we’d love to set up a time to talk!

Kim Phillips, Executive Recruiter/Search Consultant
Morgan Consulting Resources, Inc.
Kim@morganconsulting.com

Rosie Saenz, Executive Recruiter/Search Consultant

Morgan Consulting Resources, Inc.
rosie@morganconsulting.com


POSITION DESCRIPTION

Company: Inland Empire Health Plan
Position Title: Director, Grievance & Appeals
Department: Grievance & Appeals
Division: Health Services
Reports To: Executive Director, Health Services Operations
Location: Rancho Cucamonga, CA

Position Summary

Under the direction of the Executive Director of Health Services Operations, the Director of Grievance and Appeals is responsible for directing and overseeing the Grievance and Appeals Department teams and processes to ensure timely, effective and compliant grievance and appeals (G&A) processes. The Director of Grievance and Appeals guides and develops the Grievance and Appeals leadership team ensuring that all operations meet compliance standards as outlined by DMHC, DHCS, CMS, and NCQA. The Director of Grievance and Appeals is also responsible for leading any regulatory audits and oversight activities in the areas of G&A.


Position Responsibilities

  • Ensure department compliance with regulatory required grievance and appeals processes and activities, as mandated by CMS, DHCS, DMHC and NCQA.
  • Direct and oversee Grievance and Appeals department to ensure team understanding and compliant processes of regulatory requirements.
  • Serve as Audit Lead on all Grievance and Appeals audits conducted by IEHP regulatory agencies.
  • Facilitate effective communications with regulatory agencies, including State Fair Hearings, ensuring comprehensive, effective and timely responses to inquiries.
  • Responsible for understating regulatory requirements as they relate to Grievance and Appeals operations and protocols and apply that knowledge to ensure departmental compliance.
  • Responsible for ensuring electronic systems utilized by the Grievance and Appeals department meet departmental operations and regulatory compliance needs. These systems include: call center systems, medical management documentation systems, reporting systems.
  • Responsible for the oversight of departmental policies and procedure to ensure compliance with IEHP Regulators (DMHC, DHCS, NCQA, and CMS).
  • Lead collaborate efforts with impacted IEHP departments in the development, implementation and evaluation of quality initiatives that stem from grievance and appeal data trends.
  • Serve as Co-Chair of the Grievance Trend Review Committee, providing direction, and recommendations based on grievance and appeals trends.
  • Direct and oversee the process of handling difficult Providers and/or escalated cases. This process includes research of grievance and appeal history, possible operational barriers, and communications with Providers and Members to ensure customer service standards are met and resolutions occur.
  • Responsible for reviewing grievances and appeals to identify and recommend opportunities for improvement. Analyze data including quality of care referrals and Grievance & Appeals cases to develop quality and process improvement initiatives around quality of care, access, and Member and Provider satisfaction.
  • Demonstrate a commitment to incorporate LEAN principles into daily work.
  • Establish and maintain effective working relationships with others throughout the organization.
  • Any other duties as required to ensure the Health Plan operations are successful.
  • Ensure the privacy and security of PHI (Protected Health Information) as outlined in IEHP’s policies and procedures relating to HIPAA compliance.

Minimum Requirements

Education/License:

  • Possession of a valid clinical license issued by the State of California required. Clinical licensure requirement can be met via: Physician Assistant (PA, PA-C), Nurse Practitioner (NP), Family Nurse Practitioner (FNP), Adult Nurse Practitioner (ANP), Pharmacist (PharmD), or Registered Nurse (RN).
  • Bachelor’s degree in a health-related field from an accredited four-year institution preferred.
  • Valid State of California driver’s license.

Experience:

  • A minimum of two years’ experience leading healthcare utilization management or care management teams required.
  • Four or more years’ experience in quality assurance, utilization management, case management, and/or provider liaison duties, preferably in an HMO or Managed Care setting preferred.
  • Two or more years’ experience working in a clinical setting required.
  • Strong knowledge of State of California and Federal grievance and appeal regulations.

Knowledge/Skills Required:

  • Excellent written and verbal communication skills that adapt to targeted audience.
  • Strong team leadership skills.
  • Ability to demonstrate critical thinking, strong problem solving capability.
  • Strong attention to detail.
  • Positive attitude and ability to develop teams that are productive, adaptive and collaborative.

Commitment to IEHP Team Culture

The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members, Providers, and external associates.