Dir GAU

Please email HR_Talent_AcquisitionTeam@bcbsri.org if you are a candidate seeking a reasonable accommodation for the application and/or interview process.

We come from varying backgrounds, different cultures, and unique experiences. We are hard-working, caring, and creative individuals who collaborate, support one another, and grow together. Passion, empathy, and understanding are at the forefront of everything we do—not just for our members, but for our employees as well.

Direct the development and administration of unit responsible for the resolution of member and provider grievances and appeals.  Oversee the coordination of member and provider complaints, grievances and appeals for all products.  Ensure policies, procedures, and operations are consistent with state and federal guidelines and Centers for Medicare and Medicaid Services (CMS) requirements.  Ensure programs, plans, and policies align with the company’s philosophy and objectives. 

• →Oversee the work of the business unit responsible for the resolution of member and provider grievances and appeals.  Provide leadership and direction to first line management including performance management oversight and employee development.
• →Direct the implementation and administration of the company’s member and provider grievance and appeals programs. 
• →Oversee the coordination, research, negotiation, and resolution of member and provider complaints, grievances and appeals for all products. Ensure timely and accurate achievement of performance measures. 
• →Ensure the timely submission of regulatory reporting.
• →Oversee the completion of program metrics, monitoring improvement and compliance.
• →Develop and implement quality improvement strategies based on the identification of the origin of complaints and appeals.  Monitor and measure process improvement.
• →Ensure policies and procedures are current with all state and federal regulations and CMS requirements to ensure organizational compliance.
• →Develop and ensure adherence to goals and deadlines.
• →Perform other duties as assigned.

• Bachelor’s degree in Business Management, Business Administration, or Healthcare Administration or related field, or an equivalent combination of education and experience
• Seven to ten years experience in managed care or health plan operations
• Five to seven years management experience or experience leading a team
• Complaint resolution experience
• Knowledge of regulatory requirements under Medicare/Medicare Managed Care and the Part D programs
• Knowledge of grievance and appeals processes
• Knowledge of health insurance laws and regulations
• Ability to collaborate while dealing with complex situations
• Ability to think creatively and to drive innovation
• Ability to influence up and across the organization
• Ability to motivate, lead and inspire a diverse group to a common goal/solution with multiple stakeholders
• Ability to convert business strategy into action oriented objectives and measurable results
• Ability to develop and manage a budget
• Strong negotiating, influencing, and consensus-building skills
• Ability to mentor, coach and provide guidance to others

• Rhode Island Registered Nurse License

Location:
BCBSRI is headquartered in downtown Providence, conveniently located near the train station and bus terminal. We actively support associate well-being and work/life balance and offer the following schedules, based on role:

• In-office: onsite 5 days per week
• Hybrid: onsite 2-4 days per week
• Remote: onsite 0-1 days per week. Permitted to reside in the following states, pending approval from the Human Resources Department: Arizona, Connecticut, Florida, Georgia, Louisiana, Massachusetts, North Carolina, Oklahoma, Rhode Island, South Carolina, Texas, Virginia
   

Our culture of belonging at Blue Cross & Blue Shield of Rhode Island (BCBSRI) is at the core of all we do, and it strengthens our ability to meet the challenges of today’s healthcare industry. BCBSRI is an equal opportunity employer.

The law requires an employer to post notices describing the Federal laws. Please visit  www.eeoc.gov/know-your-rights-workplace-discrimination-illegal to view the "Know Your Rights" poster.