Team Leader, Appeals

About the role

We are hiring for a Team Leader, Appeals to supervise the process to ensure the resolution of appeals, coding disputes and grievances consistent with organizational policies and procedures and which are compliant with state and federal guidelines. This individual will oversee daily operations and case-load assignments and priorities for team.

Responsibilities

• Supervise staff responsible for the processing of appeals, coding disputes and grievances and coverage/organization determinations from members, member's representatives, providers, media outlets, senior leadership and regulatory agencies with established regulatory and accreditation guidelines.
• Take action, make decisions, and shape team or group priorities to reflect the organization’s core competencies.
• Guide and motivate others to take appropriate actions.
• Consult with appropriate staff in preparation of Appeals Committee and panel meetings.
• Handle and/or direct the handling of difficult customer calls regarding appeals, coding disputes and grievances or quality issues.
• Work with staff to produce efficient and effective workflows and processes.
• Advise and instruct staff on meeting team operational goals and policies.
• Instruct staff in communication to providers and members regarding decisions and supporting rationale, and respond to concerns on behalf of Medical Management.
• Evaluate data requests to ensure data requirements are being met.
• Assist staff employees and management with their information needs.
• Responsible for all related ad hoc reporting and assigned projects/interventions.
• Work with management to continuously improve operations, resolve cross-team issues, and allocate resources across the department and other divisions, as needed.

Requirements

• Bachelor's degree or advanced degree (where required)
• 5+ years of experience in related field
• In lieu of degree, 7+ years of experience in related field

Skills

• Case Management Supervision
• Department Management
• Employee Supervision
• Healthcare Management
• Information Management
• Leadership
• Managed Care
• Mentorship