Appeals Manager

Summary

Join MedReview, a leader in payment integrity solutions, as an Appeal Operations Manager! Oversee the appeals and inquiry review process, manage staff, and monitor productivity. Guide and coach your team, assist with training, and oversee quality assurance. Collaborate with leadership on policy development and implement quality improvements. Analyze data, identify trends, and enhance processes. This full-time, remote position offers flexibility and the chance to make a significant impact on healthcare accuracy and accountability. The ideal candidate possesses strong inpatient hospital payer appeals experience, excellent communication, and analytical skills.

Requirements

• Associates Degree in Health Information Management, Business Administration or health related field or equivalent work experience is required
• 2+ years leadership experience in healthcare/health plan setting required
• 2+ years of appeals and grievances experience in a payer-based environment
• Proven operational excellence and building relationships across multiple teams
• Knowledge of HIPAA privacy information standards required
• Ability to prioritize and organize workloads and complete tasks independently
• Demonstrates excellence in written and oral communication including interpersonal skills
• Proficient knowledge of Microsoft Word, Excel and other business software
• Previous experience managing claims and/or claims appeals
• Knowledge of DRG validation review, cost outlier review and readmission review
• Knowledge of appeal requirements and regulations across Medicare/Medicaid businesses
• Knowledge of claim processing or claim auditing systems
• Knowledge of CMS (Medicaid/Medicare) regulations and requirements
• Ability to thrive in a fast-paced environment and manage multiple priorities
• Ability to coordinate multiple high priority issues while maintaining compliance and communication with clients
• Demonstrated strategic planning in a matrixed environment
• Strong quantitative and analytical problem-solving skills
• Detail oriented highly organized work skills
• Excellent computer skills
• Demonstrates the ability to motivate others
• Positive attitude who works well with others
• Willingness to improve workflow

Responsibilities

• Oversees workflow among employees to ensure maximum productivity and quality standards are met
• Prioritize work to ensure completion of designated area responsibilities and functions
• Works collaboratively with the Appeal leadership to ensure claims are completed timely per the client’s SLA (service level agreement)
• Interface with Appeals Leadership regarding operational issues affecting the processing of claims
• Research as needed, escalated appeals or grievances that initiate from a variety of sources, including members, providers, state/federal regulators, and others within the timeframes outlined by federal and state regulations
• Ensure positive client relationships and meeting expectations regarding appeals processing
• Coordinate with various departments to ensure timely appeal responses
• Present analysis and documentation for reviews in aggregate and interpret and identify trends and opportunities for process and program improvements
• Continuously identify opportunities to increase efficiency in workflows and operations for Appeals processes and staff
• Perform quality assurance monitoring of work performance for Appeals staff
• Monitor, mentor and provide performance feedback and evaluations for Appeals staff. Develop action plan for low performers
• Assists with orientation and training of all new hires. Assists with the Development of training aids
• Supervises all QA activities regarding the work performed by team. Reviews all monthly QA reports prior to emailing. Monitors and records team productivity and error rates. Works collaboratively with the management team to develop a plan of action for employees with high error rates, low productivity
• Works closely with the Director of Appeal Operations to ensure the on-going implementation of new policies and procedures related to the QA process
• Attend, and lead as necessary, partner-facing/external calls to deliver updates on operations and solution with markets on identified needs
• Other duties as assigned

Preferred Qualifications

• High speed internet (100 Mbps per person recommended) with secured WIFI
• A dedicated workspace with minimal interruptions to protect PHI and HIPAA information
• Must be able to sit and use a computer keyboard for extended periods of time

Benefits

• Healthcare that fits your needs - We offer excellent medical, dental, and vision plan options that provide coverage to employees and dependents
• 401(k) with Employer Match - Join the team and we will invest in your future
• Generous Paid Time Off - Accrued PTO starting day one, plus additional days off when you’re not feeling well, to observe holidays
• Wellness - We care about your well-being. From Commuter Benefits to FSAs we’ve got you covered
• Learning & Development - Through continued education/mentorship on the job and our investment in LinkedIn Learning, we’re focused on your growth as a working professional