Clinical Appeals Manager; Hybrid

Clinical Appeals Manager (Hybrid) at Care First Blue Cross Blue Shield

Overview

The Clinical Appeals Manager (Hybrid) manages the appeal process for members and providers who appeal on behalf of members for Commercial lines of business. The role ensures quality management of the clinical appeal process to reduce regulatory risk, supports NCQA accreditation, and aligns with Care Management divisional goals. The incumbent is expected to work in a hybrid model, with part of the week from home and part at a Care First location based on business needs.

• Develops, establishes and implements a compliant appeal process with dynamic goals to achieve full and fair review of appeals, align with corporate objectives, and advance departmental capabilities. Ensures appeal decisions are accurate based on the member s health benefit contract and Care First Medical Policy, and compliant with State, Federal and accreditation requirements. Resolves regulatory complaints and external review requests. Performs analytics and research to promote best practices and integrate new processes.
• Develops, implements, and monitors associate performance standards and documentation to ensure compliance with State, Federal and NCQA requirements. Manages tracking, trending, and data analysis of the end-to-end appeal experience and takes action based on findings. Manages standardized and ad hoc reporting including annual and semi-annual reports to Committees and Regulatory Agencies.
• Reviews and interprets new legislation impacting Health Services. Provides support to Legal, including evaluating and rendering informed opinions on health care delivery and outcomes, including preparation of chronologies of medical events in response to regulatory complaints and in preparation for legal disputes.
• Ensures compliance with Regulatory filings to maintain Private Review Agent Certifications. Engages with internal and external business partners and Regulatory Agencies regarding the appeal process.
• Manages day-to-day activities for appeal management, coaching and guiding associates to meet departmental, divisional, and organizational goals. Develops annual goals and monitors budgets, resources and variances.

This position manages people.

Education Level: Bachelor s Degree in Nursing, Social Work, Health Care Administration or related discipline OR, in lieu of a Bachelor s degree, an additional 4 years of relevant work experience required in addition to the required work experience.

• Licenses/Certifications: RN - Registered Nurse, State Licensure and/or Compact State Licensure Upon Hire Required; CCM - Certified Case Manager Upon Hire Preferred; LNCC - Legal Nurse Consultant Certified Upon Hire Preferred

• Experience: 5 years of experience in a managed care operational environment and/or State or Federal appeal management; 1 year supervisory or demonstrated progressive leadership experience.

• Preferred Qualifications: 3 years supervisory or demonstrated progressive leadership experience;
  Master s in Science Nursing or related field;
  Legal Nurse Consultant;
  Certified Case Manager.

• Knowledge of regulatory and accreditation requirements, appeals process and utilization management; familiarity with relevant systems.
• Medical terminology knowledge; ability to research complex issues independently.
• Mentoring and coaching abilities; capability to evaluate performance and implement improvement strategies.
• Understanding of health economics and alignment with corporate mission to ensure affordable care.
• Effective communication, teamwork, presentation, negotiation and influencing skills.
• Ability to meet deadlines and manage multiple customer service requests with professionalism.

Salary Range: $96,160 - $178,497

The disclosed range is a general guideline and not a guarantee of the actual starting compensation. Benefits, incentives, and 401k are available where eligible.

• Department: Core Clinical Operations Admin
• Equal Employment Opportunity: Care First Blue Cross Blue Shield is an Equal Opportunity employer. All qualified applicants…