Manager, Clinical Appeals & Grievances

This is a fully remote position, open to applicants in United States.

📋 Description

• Develop and organize weekend staff assignments and workload to ensure adherence to compliance standards.

• Assess and allocate expedited appeals efficiently.

• Standardize and enhance the routing of Appeals and Grievances.

• Oversee weekend appeal inventory to guarantee regulatory adherence.

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

• Maintain relationships with delegated vendors while monitoring their performance and compliance.

• Collaborate with external departments regarding escalations, clarifications, and resolution of appeals.

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

• Review requests for case changes and cancellations, routing follow-ups appropriately.

• Review and submit Level 2 appeal packets to the designated entity.

• Stay informed about industry trends, best practices, and protocols.

• Identify trends and propose improvement solutions.

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

• Cultivate partnerships within and beyond operations.

• Provide feedback and suggestions to leadership regarding staff performance.

• Uphold the confidentiality of member, provider, medical, and departmental information.

• Carry out additional responsibilities as assigned.

⛳️ Requirements

• High School Diploma or GED.

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

• Work experience showcasing strong verbal and written communication skills.

• Ability to work independently in a dynamic environment that requires managing multiple priorities at once.

• Willingness and ability to work a weekend schedule (Friday-Monday or Thursday-Sunday).

• Proficiency in Microsoft Word and Excel, corporate email, and virtual filing systems such as Macess.

• Familiarity with care management systems like CCMS, TruCare, and Hyland.

• Bachelor's degree is preferred.

• RN or LPN certification is highly preferred.

• Experience in clinical practice with a background in appeals and grievances, claims processing, utilization review, or case management is preferred.

• Understanding of Utilization Review Guidelines, including NYS ART 44 and 49 PHL, InterQual, Milliman, or Medicare local coverage guidelines is preferred.

• Must adhere to HIPAA, state and federal compliance standards, and regulatory guidelines.

🏝️ Benefits

• Medical, dental, and vision insurance (subject to eligibility criteria).

• Incentive and recognition programs.

• Life insurance (subject to eligibility criteria).

• 401k contributions (subject to eligibility criteria).

• Competitive salary and benefits package.