Team Lead - Appeals (Place of Service, Short Stay & Readmission)

Responsibilities

• Oversees audit team responsible for producing quality audit outcomes and well written sustainable findings.
• Provides support to the audit team to ensure outcomes are based on nationally recognized standards and proprietary clinical validation guidelines.
• Maintains the flow of claims ensuring adherence to client SLA’s.
• Primarily responsible for optimizing team and individual auditor performance including production, accuracy and quality deliverables.
• Responsible for handling the training and process improvements working in conjunction with the team; works with Quality Assurance to ensure auditors are meeting accuracy and quality execution of audit deliverables.
• Develops and implements remediation efforts when warranted.
• Handles employee reviews, new hire on-boarding, PTO, coaching and mentoring; monitors staff productivity.
• Serves as first level resource for the Clinical Validation auditors in terms of questions related to specific claims and clinical industry standards.
• Creates an environment that fosters information sharing.
• Collaborates with Manager and Human Resources in applying best practices to areas of Employee Relations and performance management.
• Ensures all Cotiviti and department rules and processes are followed.
• Affords assistance and coordination with manager to hire and retain top talent.
• Actively recommends system or process improvements or enhancements that will increase productivity, quality or cost containment.
• Captures system issues for IT escalation, tracks and reports downtime.
• Ensures operational controls and day-to-day processes are in place to meet client budget goals.
• Strategically distributes work among Auditors - ensuring timely completion and optimized results.
• Uses data and analytic techniques to monitor client performance to identify and remediate outliers.
• Provides metrics and information, as requested or scheduled, to include (but not limited to): hours worked, members reviewed, calls made, claims written, and dollars found.
• Elevates provider/client suggestions and concerns to appropriate Audit Manager, and offer solutions as needed.
• Ensures alignment between strategic goal setting process and performance management process to ensure the organization has the depth and breadth of talent to achieve organizational goals.
• Hire, develop, coach, lead and retain top-tier talent, with a focus on building and improving a team and culture that is able to assist in employing best in class practices to support and drive high levels of internal and external customer satisfaction.

Qualifications

• Education/Certification/Licenses: Associate or Bachelor's degree in nursing. RN License (active /unrestricted in state of residence).
• Experience: 2+ years’ prior management or supervisory experience preferred. 5+ years of related experience in: Auditing, Quality or Appeals focused on these types of audits: Place of Service, Short Stay & Readmission.
• Computer proficiency: In Microsoft Excel, Access and system databases are required.
• Other: Prior Healthcare Billing and/or claims experience desired, but not required. Ability to mentor staff and enhance performance as it relates to the quality and productivity of their audits. Requires working knowledge of and applicable industry-based standards. Excellent verbal and written communication skills. Ability to work well in an individual and team environment.