Manager, Grievance and Appeals

Navitus Health Solutions is seeking a Grievance and Appeals Manager to join our team!

The Manager of the Grievance and Appeals (G&A) Department is responsible for the day-to-day leadership/support of the G&A staff. The Manager will act as a subject matter expert (SME) for implementation teams, government program reporting, client team inquiries, call center, prior authorization, and drug information teams The G&A Manager will be responsible for all applicable departmental policies and procedures, any corrective action required as a result of internal/external audit, responding to inquiries related to G&A processes for sales and implementation. The G&A Manager will oversee all operational duties performed by the G&A team, as well as all clinical determinations made by the clinical appeal staff. The Manager, G&A serves as a point of escalation and expertise for both internal and external customers. Independent review vendors (IRO/IRE) will use the G&A Manager as a central point of contact for any communication between these organizations. In addition to staff support, monitoring and escalations, the Manager, G&A is responsible for facilitating and maintaining an environment that fosters process improvement by maintaining relationships with external review organizations, maintaining department resources, G&A reporting, tracking, trending and forecasting summaries, department representation in meetings, prepare and present for audits and will serve as a technology SME for Navitus system(s) used by the G&A department. The Manager, G&A will ensure department metrics are met through monitoring of staff performance using a multitude of software applications including Calibrio, Adobe, Visio, Excel, Crystal, and all MS Office applications.

Is this you? Find out more below!

How do I make an impact on my team?

Ensure daily workloads standards and metrics are met
• Responsible for day-to-day leadership/support of department staff
• Facilitate training/development needs for individuals and department
• Implement and maintain G/A technology resources to meet the needs of the business
• Review and prepare reports which monitor performance guarantees to/from Navitus Health Solutions
• Oversee clinical determinations made by departmental clinical staff and responsible for evaluating trends and proposing utilization management changes based on IRO/IRE determinations
• Manage and maintain resources that support G/A staff
• Act as the first point of contact with vendors, clients and internal departments
• Other duties as assigned

What our team expects from you?

• A minimum of a Bachelors Degree in Pharmacy or Pharm D. Current, unrestricted, licensure as an RPh in home state or the ability to gain licensure within 4 months of employment is required
• 3-5 years of managed care and/or insurance background preferred in addition to a strong knowledge of CMS coverage determination and redetermination processes
• Experience with CMS and/or NCQA audits strongly desired
• 1-3 years of leadership experience preferred
• Knowledge of the PBM industry, formulary management, pharmacy claims and managed care principles and practices is desired
• Proficiency in drug literature and clinical trial evaluation, including proficiency with electronic databases (e.g., Micromedex, Medline, Internet) required
• Ability to reason and translate clinical information into a manner appropriate for clinical systems and clinical/non-clinical audiences
• Requires attention to details in order to assure projects are clinically, editorially, and systems accurate and can be operationalized
• Proficiency in MS Word, Excel, Power Point including tables, charts and figures preferred
• Participate in, adhere to, and support compliance program objectives
• The ability to consistently interact cooperatively and respectfully with other employees

What can you expect from Navitus?

• Top of the industry benefits for Health, Dental, and Vision insurance

• 20 days paid time off

• 4 weeks paid parental leave

• 9 paid holidays

• 401K company match of up to 5% - No vesting requirement

• Adoption Assistance Program

• Flexible Spending Account

• Educational Assistance Plan and Professional Membership assistance

• Referral Bonus Program - up to $750!

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