Manager of Appeals & Grievances – Health Plan
Irving, TX (Dallas-Fort Worth Metro Area)
Manager of Appeals & Grievances Job Summary:
Manager of Appeals & Grievances Background:
- 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.
#ADMIN or #CLINICAL
- 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