Supv Appeals

The Supervisor of Appeals will lead a team of Appeal Specialists and Appeal Coordinators who process clinical and non-clinical appeals, and claim review requests, from all provider types, as well as clinical and non-clinical appeals and claim review requests from members. Ensures appeals are completed according to all regulatory standards as well as Corporate policies and procedures.

Responsible for ensuring that appeals processing is completed timely and accurately.Provide leadership, training, and assistance to direct reports that support the business goals of the Appeals team.

This position has a strong clinical focus. The successful candidate will have experience working with licensed clinicians at all levels and is comfortable explaining medical terminology and evaluating medical records.

Key Responsibilities:

·Ensures unit achievement of established performance, compliance, and quality metrics

·Coach, train, and develop staff to maximize team performance

·Develop desk procedures and streamline processes

·Drive operational efficiency and improve provider/member satisfaction

·Identify workflow gaps and recommend effective, actionable solutions

·Acts as a liaison with internal and external departments that interact daily with Provider Appeals

·Stays abreast of Claim Payment Policy & Medical Policy changes and communicate appeals impact

·Maintain a working relationship with associated Appeals teams and various business areas to serve as an Appeals SME and collaborate when cross-functional servicing is required

·Collaborates with various departments within the company, as well as third party vendors­ Legal, Compliance, Member Services, CMC, AIM, Medical Policy, Magellan, eviCore, and other departments to ensure appropriate appeal resolution.

·Analyze daily appeals reporting to ensure consistent servicing within the appeals team and identify trends

·Reviews management reports and controls unit inventory levels by monitoring volumes, productivity, and staffing on a daily basis; Identifies barriers and recommends solutions to the manager when process changes do not or cannot resolves issues

·Provide technical expertise related to Appeals applications and workflows

·Develop reporting for various adhoc requests

·Interviews, hires, provides ongoing feedback, recommends salary increases, and performance manages direct reports

·Able to intercede when sensitive appeals concerns arise and escalate, where appropriate

·Other duties as assigned

Education and Experience:

·Bachelor’s degree or equivalent experience ; prior experience in a leadership role preferred

·RN license highly preferred

·Minimum 5 years of progressive experience in a health care-related organization is required, with experience in Provider Networks, Contracting, Claims Processing or Managed Care

Operations strongly preferred.

·Excellent verbal and written communication

·Demonstrated ability to effectively utilize Microsoft office applications (Word, Excel, PowerPoint). 

·Strong analytical and reporting skills

·Candidate must be able to work independently, manage multiple priorities effectively and have excellent analytical, organizational and problem solving skills. 

·Proven ability to effectively interact with various levels of Management, is required.