Appeals & Grievances Manager

  • Beacon Health Options
  • Latham, New York
  • Mar 21, 2019
Medical

Job Description


Location
NY: Latham (10 British American Boulevard)

Job Family
Clinical, Unlicensed


Job Brief

We are currently seeking a dynamic Appeals Manager to join our Clinical Administrative Appeals team in Latham, NY!

About the Position:

We are currently seeking a dynamic Appeals Manager to join our Clinical Administrative Appeals team in Latham, NY! The Manager of Appeals is responsible for the supervision and oversight of non-plan-specific utilization management (UM) Administrative Appeals Coordinators, Legal Liaisons, Supervisor and Appeals Clerks within Beacon. The Manager of Administrative Appeals focuses on directing administrative appeals and regulatory complaint operational logistics and ensuring alignment with Beacon corporate strategies, managing administrative appeals, legal liaisons and appeals clerk staff, and developing strategies for meeting departmental objectives, including quality and timeliness.

Position Responsibilities:
  • Supervision and management of Administrative Appeal Supervisor, Administrative Appeals Coordinators, Legal Liaisons and Appeals Clerks through:
    • Maintaining standard workflows and protocols across plans
    • Creating Standard Operating Procedures as needed.
    • Conducting regular file audits to ensure electronic appeals and denial files are complete and accurate.
  • Manage and provide oversight of all audits for appeal and denial compliance; includes state audits, plan audits, internal audits, and accreditation audits for URAC and NCQA.
    • Review and defense of all denial and appeal files
    • Assistance with creation of all written materials to be presented
    • Presentation and defense of submitted materials
  • Monitor trends in utilization and quality metrics of administrative appeals
  • Assist the AVP, Appeals & Retros in the interpretation of UM metrics specific to administrative appeals and regulatory complaints for the organization and individual contracts
  • Develop strategies for administrative appeals teams to meet departmental objectives and key performance indicators
  • Collaborate with Beacon Appeals & Retros managers to identify overall program improvements for handling retrospective reviews and appeals cases
  • Develop and implement necessary processes to manage the receipt, investigation, and resolution of administrative appeals and regulatory within the quality standards and timeframes required
  • Maintain current knowledge of plan products, policies, and procedures with the ability to relate this information in a clear, concise, and understandable manner to members, providers, and other customers, both internal and external
  • Monitor productivity, timeliness, and quality standards for entire administrative appeals team
  • Participate in new business implementations as assigned
  • Maintain confidentiality of all protected health information in accordance with state and federal guidelines and corporate policies and procedures.
  • Maintain knowledge of all system, contractual, compliance standard changes and policy updates, and attend additional training sessions as necessary.
  • Maintain thorough knowledge of covered benefits for the populations served
  • Liaison responsibilities with multiple internal departments; Operations, Legal, Compliance, Claims, IT, Provider Relations, Staff Physicians and Clinicians.
  • Participate in provider and plan meetings as assigned
  • Administrator On-Call duties
  • Participate in NCQA and URAC activities, as assigned
  • Other duties as assigned


Position Requirements:
  • Education: Bachelor's Degree or higher in Business, Human services, or a related field is required
  • Relevant Work Experience: 3-5 years general operations and appeal management experience in the health care industry required
    • Knowledge, Skills, & Abilities:
    • Previous management of staff is required
    • Managed care experience preferred
    • Leadership skills and supervisory experience, including the ability to develop team performance
    • Excellent written and oral communication skills
    • Ability to understand and interpret UM metrics as well as identify new UM metric requirements
    • Self-motivated, able to prioritize multiple issues, excellent organizational skills, ability to track multiple projects/tasks and follow through as needed
    • Demonstrated understanding of Continuous Quality Improvement
    • Ability to manage and coordinate with internal and external departments
    • Ability to work collaboratively with internal staff and external providers
    • Must be detail oriented; able to work independently in an ever-changing environment
    • Excellent communication and negotiation skills


To Apply:

Click below on "Apply for this Position" to create a profile and apply for the position

Beacon Health Options is proud to be an Equal Opportunity and Affirmative Action Employer as well as a Drug Free and Tobacco Free Work Environment. EOE/AA/M/F/Veterans/Disabled

PM16

#CB

#GD

AAP Reporting Location:

NY - Latham

ID (Req #):

57249

FTE Status:

Full Time

Schedule:

Monday - Friday 11:30am - 8:00pm ET

Exempt

PI108637540