Responsibilities Job Summary:The Manager, Appeals is responsible for the operational oversight, regulatory compliance, performance management, and continuous improvement of the health plan's Appeals Department. This role leads the administration of member and provider appeals across Commercial, Self-Funded (ASO), and Medicare Advantage lines of business, ensuring timely, accurate, and compliant adjudication of all appeals in accordance with federal and state regulations, CMS requirements, contractual obligations, and organizational policies.
The Manager develops and implements strategies to improve appeal outcomes, ensure audit readiness, achieve regulatory compliance, optimize operational efficiencies, and enhance member and provider satisfaction. This position collaborates closely with Medical Directors, Utilization Management, Claims Operations, Compliance, Quality Management, Provider Relations, Legal, and Customer Service departments.
Benefit Highlights:- Loan Forgiveness Program
- Challenging and rewarding work environment
- Competitive Compensation & Generous Paid Time Off
- Excellent Medical, Dental, Vision and Prescription Drug Plans
- 401(K) with company match and discounted stock plan
- SoFi Student Loan Refinancing Program
- Career development opportunities within UHS and its 300+ Subsidiaries! • More information is available on our Benefits Guest Website: benefits.uhsguest.com
Qualifications Qualifications and Requirements:- Minimum 5 years of progressive healthcare payer experience.
- Minimum 5 years of leadership experience managing appeals, grievances, utilization management, claims, or related healthcare operations.
- Experience supporting Medicare Advantage plans required.
- Experience with Commercial and Self-Funded health plan operations required.
- Experience with CMS audits, regulatory oversight, and compliance activities preferred.
- BS business administration, health administration, management, or equivalent experience.
- Knowledge of State and Federal regulations as they pertain to the health insurance industry.
- Experience with STAR ratings, care cap reports and risk scores
- Knowledge of CMS, NCQA, and HEDIS regulations as they pertain to the health insurance industry
- Proven experience reviewing and analyzing statistical data to identify trends as well as potential problems/opportunities for improved service quality.
- Versed in processes improvement techniques to reduce waste, and achieve efficiencies through simplifying complex processes within the department
- Ability to develop, use, interpret and apply key business metrics required
- Ability to organize and lead key initiatives required
- Knowledgeable of developing and implementing training for adult learners
- Strong written and verbal communication with an ability to effectively communicate with all types/levels of audiences required
- Experienced presentation skills and versed in public speaking
- Detail oriented; analytical ability; strong problem-solving skills required
- Advanced proficiency with all Microsoft Office Suite (Excel, Word, Visio, Outlook), and budgetary, time and attendance (Kronos) software systems.
- Resourceful and innovative in overcoming challenges through adapting, and responding quickly to change to gain efficiencies and increase productivity
- Must be able to make independent decisions, multi-task, prioritize tasks, and work with other internal departments to meet company goals.
