Manager, Complaints Grievances- Remote

UPMC Health Plan has an exciting opportunity for a Manager, Complaints Grievances position in the Member CGA department. This is a full time position working Monday through Friday daylight hours with rotating Saturdays thar are on call. This is a remote position.

This position is responsible for management of all member complaints and grievances and practitioner and provider complaints, for all products.

Responsibilities:

• Responsible for the tracking, trending, analysis and reporting of member complaints, member grievances, and provider complaints. Responsible for performing a root cause analysis and the initiation of corrective action plans where appropriate.
• Responsible for ensuring review of monitoring reports is completed timely and accurately.
• Serve as a role model of service excellence by ensuring adherence to established operational standards related to timeliness and accuracy.
• Maintain a positive attitude, meets customer commitments and responds promptly to customer needs.
• Manage the timeliness and accuracy of (member and provider) complaints and grievance reporting requirements for regulatory agencies, internal executive staff, and ad hoc reports as appropriate.
• Manage activities relating to special projects for complaints and grievances.
• Ensure compliance with work plans and goals.
• Responsible for maintaining an integrated process to manage complaints and grievances with other departments within the Health Plan and with external delegated entities.
• Ensure that the process, monitoring, and education process is supporting achievement of targeted results established by the Health Plan.
• Manage the day to day operations of the member complaint, member grievance, and practitioner complaint process. This includes ensuring compliance with internal and regulatory standards and resolving complaints and grievances in a comprehensive manner.
• Responsible for ensuring that second level hearings are in compliance with regulatory requirements and are performed in a professional, consistent manner.
• Represent the Health Plan on internal and external forums/committees as requested.
• Support implementation of appeals tracking system.
• Responsible for the implementation and ongoing implementation of the member grievance and appeal processes related to the Medicare products
• Develop and monitor corrective action plans both internal and cross departmental.
• Responsible for ensuring processes are compliant with external regulatory bodies, as well as NCQA standards.