Our Grievance and Appeals Manager ensures the team operates efficiently, accurately, and in compliance with all regulatory requirements regarding all grievance and appeals processes. They oversees the management of escalated or high‑profile cases, supports audits and reporting, drives process improvements, and holds the position of Chairperson of the Grievance and Appeals Committee. This Grievance and Appeals Manager is accountable to maintain knowledge of industry trends, best practices, and protocols. They are accountable to build and maintain partnerships with business areas across and outside of operations to improve communication and responsiveness to the handling of member and provider appeals.
Salary Range
$100,000 ~ $110,000
The base pay offered for this position may vary within the posted range based on your job-related knowledge, skills, experience and may consider outside of this range.
Work Location
Our first consideration will be to have this employee live in the state of Wisconsin to take advantage of Hybrid work and collaboration. Employees within 45 miles of WPS Headquarters (1717 W. Broadway in Madison, WI, 53713) will be expected to be able to work 2 days a week on site on a regular basis.
**As a secondary consideration, we could offer remote work in Wisconsin.
How do I know this opportunity is right for me? If you:
- Can manage department operations, ensuring cases are processed accurately and within required timeframes.
- Thrive when providing leadership, guidance, and support to specialists through one-on-one coaching, team meetings, and ongoing development.
- Have monitored and ensured compliance with all applicable regulatory and accreditation standards, including CMS, URAC, federal and state requirements.
- Can support audits and regulatory reviews by preparing required reports and documentation.
- Would enjoy tracking grievance and appeals trends to identify opportunities for process and performance improvements.
- Like to provide guidance and support to staff on escalated, complex, or high visibility cases.
- Want to collaborate with regulatory, clinical, and cross functional teams to address issues and enhance processes.
Minimum Qualifications
- Bachelor’s degree in Business or Healthcare Administration or related field with coursework in insurance and medical terminology; or equivalent post high school education and/or work-related experience.
- 7 or more years of health plan operations experience such as grievance and appeals, call center, claims, utilization management, pharmacy, or provider services.
- 3 or more years in a senior level individual contributor or managerial role.
- Knowledge of federal and state grievance and appeal regulations, including CMS requirements.
- Strong knowledge and understanding of grievance and appeals, call center, claims, utilization management, pharmacy, or provider services.
- Excellent operational and organizational skills with the ability to manage multiple priorities including:
- Strong analytical, problem-solving, and decision-making abilities.
- Excellent verbal and written communication skills with proven ability to communicate effectively at all levels.
- Demonstrated ability to collaborate across teams to produce results.
- Ability to handle complex, regulated work in a fast-paced environment.
- Ability to manage escalated and sensitive issues with professionalism.
Preferred Qualifications
- 5 or more years in a senior level individual contributor or managerial role in Grievance and Appeals.
- Health insurance background in Point of Service (POS), Preferred Provider Organization (PPO), or Medicare Supplement) plans.
Remote Work Requirements
- High speed cable or fiber
- Minimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection (can be checked at https://speedtest.net).
- Please review Remote Worker FAQs for additional information.
Benefits
- Remote and hybrid work options available
- Performance bonus and/or merit increase opportunities
- 401(k) with a 100% match for the first 3% of your salary and a 50% match for the next 2% of your salary (100% vested immediately)
- Competitive paid time off
- Health insurance, dental insurance, and telehealth services start DAY 1
- Professional and Leadership Development Programs
- Review additional benefits: (https://www.wpshealthsolutions.com/careers/)
Who We Are
WPS, a health solutions company, is a leading not-for-profit health insurer and federal government contractor headquartered in Madison, Wisconsin. WPS offers health insurance plans for individuals, families, seniors and group health plans for small to large businesses. We process claims and provide customer support for beneficiaries of the Medicare program and manage benefits for millions of active-duty and retired military personnel across the U.S. and abroad. WPS has been making healthcare easier for the people we serve for nearly 80 years. Proud to be military and veteran ready.
Culture Drives Our Success
WPS’ culture is where the great work and innovations of our people are seen, fueled and rewarded. We accomplish this by creating an open and empowering employee experience. We recognize the benefits of employee engagement as an investment in our workforce—both current and future—to effectively seek, leverage, and include differing and unique perspectives that fuel agility and innovation on high-performing teams. This results in people bringing their authentic selves to work every day in an organization that successfully adapts to business changes and new opportunities.
We are proud of the recognition we have received from local and national organization regarding our culture and workplace: WPS Newsroom - Awards and Recognition.
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Skills Required
- Bachelor's degree in Business or Healthcare Administration or related field
- 7 or more years of health plan operations experience
- 3 or more years in a senior level individual contributor or managerial role
- Knowledge of federal and state grievance and appeal regulations, including CMS requirements
- Strong knowledge and understanding of grievance and appeals processes
What We Do
WPS Health Solutions is celebrating 75 years in business as a highly regarded government contractor and leader in the insurance industry. In 2021, the Wisconsin State Journal named WPS as a Top Workplace in the Madison area. WPS has several divisions committed to delivering high-quality service to our customers. - WPS Health Insurance and WPS Health Plan offer affordable health plans for individuals, small businesses, and large businesses, plus benefits administration. - WPS Government Health Administrators administers Part A and Part B Medicare benefits—services we have provided since the program’s inception—for millions of seniors in multiple states. - WPS Military and Veterans Health serves millions more beneficiaries who are active in the U.S. military, veterans, and their families. - EPIC Specialty Benefits has offered voluntary nonmedical benefits, such as term life, disability, dental, and vision, for more than 35 years. WPS also actively partners with nonprofit organizations to help make lasting changes in the communities we serve, with an emphasis on health issues, especially for military and veterans, women, and children.
