Manager, Clinical Appeals – Grievances

This is a fully remote position, open to applicants in New York.

📋 Description

• Oversee and track the appeal inventory for a team of Appeals & Grievances Clinical Specialists.

• Organize and schedule weekend staff assignments and workload to ensure adherence to compliance standards.

• Assess and allocate expedited appeals while optimizing the routing of appeals and grievances.

• Manage weekend inventory to guarantee regulatory compliance.

• Communicate and escalate cases to Medical Peer reviewers as necessary.

• Maintain relationships with delegated vendors and oversee their performance and compliance.

• Collaborate with external departments for case escalations, clarifications, and appeal resolutions.

• Manage the review and printing of letters and coordinate expedited printing with the mailroom.

• Evaluate case change requests and cancellations, routing follow-ups appropriately.

• Review and submit Level 2 appeal packets.

• Stay updated on industry trends, best practices, and protocols, sharing enhancements across enterprise units.

• Identify trends and propose improvement solutions.

• Implement strategies to achieve production, compliance, and quality targets.

• Foster partnerships within and outside operations to enhance communication and responsiveness.

• Provide feedback and suggestions to leadership regarding staff performance.

• Comply with HIPAA regulations and ensure confidentiality.

• Adhere to state and federal compliance and regulatory standards.

• Perform additional responsibilities as assigned.

⛳️ Requirements

• High School Diploma or GED required.

• Demonstrated work experience in appeals and grievances or within a healthcare setting.

• Experience showcasing verbal and written communication abilities.

• Proven ability to work independently in a fast-paced environment managing multiple priorities at once.

• Availability and willingness to work a weekend schedule (Fri-Mon or Thurs-Sun).

• Proficient in Microsoft Word and Excel, corporate email, virtual filing systems like Macess, and care management systems such as CCMS, TruCare, and Hyland.

• Preferred: Bachelor’s degree.

• RN or LPN license strongly preferred.

• Preferred experience in clinical practice, appeals and grievances, claims processing, utilization review, or utilization/case management.

• Demonstrated understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, Milliman, or Medicare local coverage guidelines.

🏝️ Benefits

• Medical, dental, and vision coverage.

• Incentive and recognition programs.

• Life insurance.

• 401k contributions.

• Competitive compensation and benefits package.