Manages the formal appeal and complaint process to ensure the resolution of appeals and complaints consistent with organizational policies and procedures and which is compliant with state and federal guidelines for both administrative and clinical inquiries. Oversees daily operations and case load assignments/priorities. Recruits, hires, trains and coaches staff. Requires 3-5 years prior managerial experience.
Trends appeal issues, implements revised department procedures and recommends corporate policy and procedure changes to reduce the volume of appeals and improve customer satisfaction. Ensures timely, accurate, and compliant appeals processing for efficient corporate processes to avoid regulatory or accreditation penalties
Job Duties and Responsibilities:
- Manages the administrative activities for the Clinical Services Appeals department through oversight of the triage, intake, scheduling and filing functions for all lines of business.
- Trends complex claim and clinical issues that generate appeals to determine root cause and appropriate recommendations for improvement.
- Leads the implementation of technical and many non-technical projects required to become compliant with new regulations/accreditation standards, enhance efficiency, and improve departmental and corporate processes.
- Validates and approves regulatory, management and production reports on behalf of the department and maintains relationship with the Informatics team.
- Directs the efforts of the senior business analyst(s) who independently provides reporting as required by regulatory agencies and coordinates projects for Appeals and Complaints, analyze departmental data, recommend process improvements for management or other departments to implement and assist with the implementation.
- Oversees the workflow and triage responsibilities to assure that procedures are implemented to support timely and accurate work that includes: determining which issues are appeals and the appropriate department to handle the work, appropriately categorizing the appeals (expedited/standard, clinical/non-clinical, pre-service/post service) according to regulatory/accreditation standards, providing initial research to investigate staff, and routinely and consistently applying the administrative exception procedure.
- Oversees the intake responsibilities of the appeals department to assure that procedures are implemented to support timely and accurate work that includes: mail tracking, authorization mailing and follow-up, acknowledgement letter generation and data-entry into application processing platform.
- Oversees the file management responsibilities of the appeals department.
- Establishes and oversees procedures to ensure that member files are secured according to corporate record retention guidelines and archived according to standards.
- Develops, implements and manages the post-intake non-clinical member appeals processes for all lines of business. Assures that procedures are implemented to support the timely and accurate investigation and effectuation of expedited and standard medical necessity appeals in accordance with regulatory/accrediting standards.
- Creates and maintains processes for staff to thoroughly, accurately and independently investigate and bring to decision makers the wide variety of appeal issues presented.
- Assures associates have access to and reference to guidelines and policies including, but not limited to: medical policy, benefits, network rules, claims coding and payment guidelines, medical necessity criteria, contracting, and enrollment.
- Establishes guidelines for documenting the facts of the appeal and the determination in the case file, database, and letters. Ensures staff documentation is accurate, clear, and concise.
- Ensures staff meets productivity and quality standards results through planning and goal setting. Assures that staff has adequate training and open lines of communication to escalate issues and recommend solutions.
- Partners with the Legal, Compliance and Account Management teams to resolve regulatory, accreditation or corporate risk related concerns.
- Regularly assesses new Medicare accreditation standards and regulatory requirements and adjusts the Medicare appeals and grievances process to assure compliance.
- Assures that staff routinely and consistently applies the departmental policies and procedures.
- Utilizes daily reports to manage inventory of appeals. Develops and establishes monitors for a consistent and compliant appeal adjudication process. Analyzes reports to assess performance and compliance. Utilizes audit feedback.
- Collaborates with other appeals leaders to ensure consistent and compliant appeal adjudication process. Analyzes reports to assess performance and compliance.
- Utilizes audit feedback.
- Collaborates and coordinates with other appeal leaders to resolve appeal issues arising from blending clinical and claims issues.
- Ensures that the Appeals Nurse line is staffed on weekends, holidays and any other days the office is closed.
- Manages the implementation of inter- and intra-departmental projects by working with colleagues inside and outside the department. Develops new business/program initiatives and lead the department's technical and many non-technical initiatives (i.e. new accounts, new products, new UM policy/procedure, system enhancements, etc) to accomplish them on time and in budget.
- Facilitates and ensures all appeal determinations involving claims issues are resolved as the committee directed to include all payment, adjustments and administrative checks creation. Researches or oversees the research of unusual high-level or complex claim issues that generate appeals. Recommends revisions to corporate and/or department procedures and lead implementation of recommendations.
- Maintains detailed knowledge of department policies and procedures, systems, provider contracts, and compliance requirements in order to make sound decisions when corporate and departmental programs are created or revised. Keeps current with issues facing the corporation and the marketplace.
- Collaborates with other areas such as Care Management Coordination, Magellan, Legal, Compliance, Medical Directors, Account Management, Claims Payment Policy to resolve individual appeal problems and identify process improvements.
- Oversees determination letter process and all other letters including withdrawal and extensions, in accordance with regulatory/accreditation standards.
- Serves as a point of contact with our clients on appeal matters.
- Performs other duties as assigned
- RN License/BSN required
- 8 years progressive related experience to include established professional experience in claims, appeals or service operations environment with project management experience required.
- Prior supervisory experience with demonstrable skills required, preferably within an operations team. Appeals experience helpful.
- Must have working knowledge of healthcare delivery systems, claims payment policy, claims and utilization management procedures and the related computer systems, as well as Word and Excel.
- Working knowledge of various claims, UM, enrollment and other systems used by the AHA.
- Family of Companies and related operational procedures required.
- Demonstrated leadership, organizational, interpersonal and verbal and written communication skills required.
- Excellent problem solving, and analytical skills required. Experience with modifying processes and developing procedures around the processes.
- Ability to prioritize work and analyze workflow deficiencies to improve processes.
- Ability to prioritize varied tasks within multiple assignments and analyze workflow to recommend improved processes.
- Ability to work well effectively under deadline pressure.
- Experience with regulatory policy oversight and management; to include State, Federal NCQA, and DOI entities.
- Experience developing action plans and recommendations based on audit results and regulatory changes.