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Project Manager Lead NON IT - 30935-1
601 Potrero Grande Drive Monterey Park, California 91755 | Contract
The Appeals and Grievance Project Lead is responsible for effectively identifying and communicating the needs of the department. Assisting with the development of new processes and workflows that will ensure compliance with all regulatory bodies. Ability to prioritize competing priorities and to quickly adapt to change.
ESSENTIAL DUTIES AND RESPONSIBILITIES (in descending order of importance):
Supports the Appeals and Grievance and Provider Dispute Departments with the migration and implementation of all necessary workflows to the new platforms and systems.
Define, analyze, and capture the core business processes and work procedures and communicate them effectively to all necessary parties (project managers, management and data analyst).
Provides analytical support through the analysis and interpretation of regulatory requirements, policies and processes in support of interdepartmental operations and the departments that we interact with.
Identifies opportunities for improvements and works cross-functionally to assist with the design and development of future business solutions.
Identifies and documents opportunities for improvement in operational performance and notifies management of issues and problems requiring immediate attention.
Identifies and documents test scenarios - coordinates the execution of test cases and records test results for SIT, UAT and monthly releases.
Develops, prepares, analyzes and presents reports for management review.
Minimum and Preferred Qualifications:
Experience in Medicare Part D, Medicare Advantage and Medi-Cal benefits management with no less than 2 years appeals and grievance and provider dispute resolutions experience.
Knowledge of the appeals and grievance regulations of the Centers for Medicare & Medicaid Services, the Department of Health Care Services, the Department of Managed Health Care and LA Care.
Demonstrated ability to positively influence others, exercise sound judgment with limited direction to identify and resolve complex problems using logic and regulation.
Knowledge of NCQA regulation is a plus
High School diploma/GED required Advanced degree preferred
Skills/Abilities: Strong knowledge of health benefit plan design and health care operations Strong communication and presentation skills (written and oral) Strong analytical and problem solving skills
Strong working knowledge of Microsoft Office (Word, Excel, Access and PowerPoint). Access is a plus.
Positive attitude and willingness to take on new challenges.