Grievance & Appeals Audit & Project Lead

Summary of Job

Coordinate all phases of Grievance and Appeal regulatory and accreditation audits including universe generation and case file compilation, during which all submissions are quality checked and risks are identified and mitigated to the extent possible. Serve as subject matter expert (SME) and liaison between business partners such as IT, Legal, Compliance. Analyze current processes against new regulations/requirements; make determinations on needed changes; collaborate with Leader and other department leadership and stakeholders to drive all necessary changes. Support the G&A Systems & Project Leader as a G&A systems (CAG) SME, responsible for submission and tracking of support tickets, conducting UAT and troubleshooting issues.

Responsibilities:

• Responsible for the fulfillment of G&A universe requests, including holistic validation, logic checks and quality review of all data elements.
  Interact with, respond to, and present to regulatory and accreditation auditors.
• Drive development of responses, through engagement with the G&A team, to any findings or requests for information, conducting applicable impact analysis and providing responses to regulatory and accreditation audit requests, meeting all deadlines. Ensure that all responses meet quality guidelines for completeness, accuracy, and timeliness.
• Letter administrator, responsible for development and programming of letter content, ensuring minimal manual updates to letters are requirement by G&A staff, thereby reducing risk of errors and increasing productivity.
• Responsible for continuous improvement of letter templates, implementing changes based on feedback and needs of the team.
• Provide expertise and vision with respect to planning, development and execution of G&A projects and implementations.
• Oversee/evaluate team activities and functions to ensure success and achievement of financial and timeline targets.
• Manage resources and priorities, risk mitigation, metric management, analysis, contingency planning, and reporting.
• Maintain solid knowledge and understanding of G&A processes and requirements to ensure projects are implemented appropriately and risks to the business are mitigated.
• Support G&A team to troubleshoot system issues, escalating to vendor as appropriate.
• Submit support desk tickets ad track progress/completion, monitoring monthly support hour usage.
• Identify technology-based pain points and drive solutioning, increasing employee satisfaction by ensuring they have the optimal tools to complete job functions.
• Conduct UAT testing on a quarterly and/or ad-hoc basis to ensure business processes are behaving as intended and there is no impact to operations as a result of IT releases.