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Manager of Appeals & Grievances

Dallas, TX · Healthcare
Manager of Appeals & Grievances – Health Plan
Irving, TX (Dallas-Fort Worth Metro Area)
 
Manager of Appeals & Grievances Job Summary:
  • Manages staff responsible for the submission/resolution of inquiries, appeals and grievances for Marketplace. 
  • Ensures resolutions are compliant.
  • Proactively assesses and audits business processes to determine those most effective and efficient at resolving problems.
  • Serves as primary interface with internal business counterparts and ensures standard processes are implemented
  • Oversees preparation of narratives, graphs, flowcharts etc… to be used for committee presentations, audits and internal/external reports; oversees necessary correspondence in accordance with regulatory requirements.
  • Maintains call tracking system of correspondence and outcomes for appeals and grievances.
  • Oversees monitoring of each submission/resolution to ensure all internal and regulatory timelines are met.
Manager of Appeals & Grievances Background: 
  • 4 Year College Degree or equivalent relevant leadership experience required
  • Prefer 3-4 years of Medicare grievance and appeals experience
  • Requires 4-6 years’ experience in healthcare claims review and/or member dispute resolution.
  • Requires experience reviewing all types of medical claims (e.g. HCFA 1500, Outpatient/Inpatient UB92, Universal Claims, Stop Loss, Surgery, Anesthesia, high dollar complicated claims, COB and DRG/RCC pricing).
  • Ability to lead cross functional teams, mentor and support the development of associates
  • Strong foundation of Revenue Cycle functions and denial management; or ability to transfer equivalent knowledge to quickly become proficient
  • Familiarity with management reporting, metrics and goal setting
  • Ability to work independently, achieve tight deadlines and take initiative on multiple projects
  • Ability to make sound decisions that are generally guided by core values, mission and policies and procedures (or) escalate when needed
#ADMIN or #CLINICAL
 
RON AMODIO
STRATEGIC DIRECTOR, EXECUTIVE SEARCH DIVISION

CareNational
ron@carenational.com
480.269.9491 (CALL – TEXT – FAX)
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