Manager of Clinical Appeals and Grievances

About the role

The Manager, Clinical Appeals & Grievances leads, operates, and advises a dynamic and fast-paced Clinical Appeals & Grievances team. This role collaborates with multiple leaders to identify priority focus areas, standardize and optimize processes, and communicate performance to various stakeholders.

Responsibilities

• Manages a team of specialists, with responsibility for goal and productivity management, coaching and counseling, performance management and other leadership responsibilities as assigned
• Provides oversight in case research and provides advice as needed
• Understands HF’s internal health plans’ policies and procedures to frame decisions
• Interprets regulations to provide guidance to specialists on a daily basis
• Ensures the timely resolution of cases and makes critical decisions
• Focuses on clinical criteria for expedited cases
• Determines best practices and strategically deploys approaches to meet production, compliance and quality targets
• Works with leadership to establish and implement departmental goals, establish monthly goal review process and implement a plan of action for identified gaps
• Guides in the preparation of case preparation for Medical Director Review ensuring that all pertinent information (i.e. case summary, contract information, internal and external responses, diagnosis, and CPT codes and descriptions) has been obtained during investigation and is presented as part of the case
• Oversees case preparation for Maximus Federal Services, Fair Hearing, and External Appeal through all levels of the appeal process
• Assists in leading the AOR / WOL Outreach team in coordination with the supervisor
• Works with Providers and DSE on educating providers in how to submit Appeals timely and accurately
• Maintains delegated vendor relationship and ensures vendor performance and compliance measures are met
• Institutes and manages working relationships within various operational areas to identify and execute overall process improvements
• Diagnoses and understands operational challenges in addition to skill gaps in order to provide leadership and management to the Appeals & Grievances team
• Identifies trends and recommends solutions for improvement
• Drives the development of innovative tools, systems, and processes to assist in overall handling of Appeals & Grievances functions
• Maintains knowledge of industry trends, best practices and protocols and collaborating with other parts of the enterprise to ensure general consistencies and enhancements

Requirements

Minimum Qualifications:

• Bachelor's degree from an accredited institution or equivalent work experience
• RN
• Experience with utilization management or appeals and grievance processing and compliance
• Working experience in a fast-paced environment overseeing multiple priorities, tasks and/or teams
• Proven track record of exercising independent thinking, ability to problem solve, understand process flows and correlating platforms to recommend and implement solutions
• Demonstrated ability to build and foster effective relationships

• Experience in clinical practice with a focus in appeals & grievances, claims processing, utilization review or utilization management/case management
• Demonstrated understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, Milliman or Medicare local coverage guidelines
• Extensive experience in healthcare appeals
• MBA or master's degree from an accredited institution with focus in training & development, education, business, or healthcare administration
• Management experience in an operational department within the healthcare industry focused on clinical leadership
• Leadership experience in a focus area of operational excellence or audit
• Experience developing strategy and processes for a department or function
• Experience managing vendors as an extension of a core team
• Familiar with creating accountable ownership of a vendor team

Benefits

Healthfirst offers a full range of benefits including medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions. The hiring range for this position varies based on location and includes a salary range of $88,700 - $131,920 for NY, NJ, CT residents and $103,400 - $149,430 for other locations. Healthfirst also provides competitive compensation and benefits packages wherever its employees work and live.