Mgr Clinical Appeals and Grievances

The Manager, Clinical Appeals & Grievances is responsible for leading, operating, and advising a dynamic and fast-paced Clinical Appeals & Grievances team. This role works closely with multiple leaders in the organization to identify priority focus areas for Appeals & Grievances, to standardize and optimize processes, and to communicate performance to multiple stakeholders. In tandem with these efforts, this individual will oversee internal and external production teams to ensure consistent production, high quality and to maintain compliance on all levels.

This role will remain flexible while utilizing strategic thinking and creativity to address challenges in alignment with long term growth and profitability goals of Healthfirst.

• Manages a team of specialists, with responsibility forgoal and productivity management, coaching and counseling, performance management and other leadership responsibilities as assigned
• Provides oversight in case research and provides advice as needed
• Understands HF’s internal health plans’ policies and procedures to frame decisions
• Interprets regulations to provide guidance to specialists on a daily basis
• Ensures the timely resolution of cases and makes critical decisions
• Focuses on clinical criteria for expedited cases
• Helps standardize and optimize how Appeals and Grievances are routed
• Determine best practices and strategically deploy approaches to meet production, compliance and quality targets
• Works with leadership to establish and implement departmental goals, establish monthly goal review process and implement a plan of action for identified gaps
• Provides guidance in the preparation of case preparation for Medical Director Review ensuring that all pertinent information (i.e. case summary, contract information, internal and external responses, diagnosis, and CPT codes and descriptions) has been obtained during investigation and is presented as part of the case
• Has oversight in case preparation for Maximus Federal Services, Fair Hearing, and External Appeal through all levels of the appeal process
• Assists in leading the AOR / WOL Outreach team in coordination with the supervisor
• Works with Providers and DSE on educating providers in how to submit Appeals timely and accurately.
• Maintains delegated vendor relationship and ensure vendor performance and compliance measures are met
• Institutes and manages working relationships within various operational areas to identify and execute overall process improvements
• Diagnoses and understands operational challenges in addition to skill gaps in order to provide leadership and management to the Appeals & Grievances team
• Identifies trends and recommends solutions for improvement.
• Drives the development of innovative tools, systems, and processes to assist in overall handling of Appeals & Grievances functions
• Maintains knowledge of industry trends, best practices and protocols and collaborating with other parts of the enterprise to ensure general consistencies and enhancements
• Additional duties as assigned

• Bachelor's degree from an accredited institution or equivalent work experience
• RN
• Experience with utilization management or appeals and grievance processing and compliance
• Working experience in a fast-paced environment overseeing multiple priorities, tasks and/or teams
• Proven track record of exercising independent thinking, ability to problem solve, understand process flows and correlating platforms to recommend and implement solutions
• Experience preparing and delivering written and verbal information to multiple types of audiences
• Demonstrated ability to build and foster effective relationships

• Experience in clinical practice with a focus in appeals & grievances, claims processing, utilization review or utilization management/case management.
• Demonstrated understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), Inter Qual, Milliman or Medicare local coverage guidelines
• Extensive experience in healthcare appeals
• MBA or master's degree from an accredited institution with focus in training & development, education, business, or healthcare administration
• Management…