Manager, Provider Appeals

Job Details

Oversee the day-to-day operation of the Provider Appeals Department. Provide supervision to Appeals coordinators, to ensure compliance with the UM Program, NCQA Standards and all applicable government regulations.

Job Description

Primary Responsibilities:

• Manage cross-functional employees to meet and exceed service requirements and functional objectives.
• Recruit, develop, motivate and retain a high caliber of team members.
• Coach and lead team to continuously improve operational performance.
• Monitor and maintain service level goals for the Provider Appeals department.
• Establish productive working relationships with Hospital Managers/Directors of UM, Claims and Admissions
• Provide ongoing education to the Hospital Managers and Directors regarding HP appeals process changes.
• Establish auditing tools for monitoring which support regulatory and accredited bodies.
• Participate in regulatory (DPW, DOH, NCQA) site visits.
• Establish activities and monitor goals for NCQA, DPW and CMS guidelines
• Implement clinical guideline changes as well as process changes to meet department objectives.
• Maintain a positive work environment that supports self-direction; provide a structure to optimize experience, skill, knowledge and capability of the team.
• Reward team members based on contribution and performance.
• Participate in the development and supervise the implementation of all departmental policies and procedures and goals.
• Maintain a central role in promoting appropriate communication between UM, Claims, Member and provider service representatives and HP subcontractors.
• Interpret appeals procedures for coordinator staff, other HP staff, network hospitals and other external audiences.
• Recruiting new staff and assigning staff responsibilities.
• Perform employee evaluations for the Appeals Coordinators and Appeals Team Lead.
• Review requests and make determinations for requests for time-off for the Coordinators and Pre Cert Nurses.
• Work effectively with the Director to carry out the goals of the department.
• Work on special projects as needed
• UMC liaison for Precertification and appeals.

Key Job Requirements:

Education:

• Licensed Registered Nurse, must have an active license to practice professional nursing in the Commonwealth of Pennsylvania
• 2 years medical/surgical in addition to utilization review or pre-certification experience in a managed care environment.
• Experience with the appeals plus 2 years of experience in management.
• BSN preferred.

Skills/Abilities:

• Knowledge of HMO delivery systems, Precertification, and medical terminology.
• Strong ability in applying clinical criteria to requested services.
• Strong Management experience that can be applied in guiding staff in clinical determinations.
• Strong written and oral communication skills.
• Experience in analyzing and interpreting data for clinical performance.
• Must present polished professional image.
• Ability to work and communicate effectively with co-workers, members and providers.
• Must be organized, detailed oriented, and capable of handling multiple issues.
• Computer literate.

Medicare Advantage Compliance Statement: Compliance with all applicable rules, regulations and laws is a condition of employment. Employees must read and sign, both the Business Code of Conduct and the Personal Standard Code of Conduct, and are expected to perform their duties ethically and honestly.

Access to Protected Health Information: UMC, DPW. CMS, NCQA

Work Shift

Workday Day (United States of America)

Worker Sub Type

Regular

Employee Entity

Health Partners Plans, Inc.

Primary Location Address

1101 Market, Philadelphia, Pennsylvania, United States of America

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University , home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health , nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.

Jefferson is committed to providing equal educational and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status.

Benefits

Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps ), have access to medical (including prescription) insurance.

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