MedReview is hiring a
Manager

Summary

MedReview is seeking an Appeal Operations Manager with experience in Inpatient Hospital (On behalf of Payer) claims processing. The role involves overseeing the appeal & Inquiry review process, managing the Appeals department staff, and ensuring claims are completed timely per the client’s SLA. The position offers remote work flexibility within the United States.

Requirements

• Associate's 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
• Works collaboratively with the Appeal leadership to ensure claims are completed timely per the client’s SLA
• Interfaces with Appeals Leadership regarding operational issues affecting the processing of claims
• Researches as needed, escalated appeals or grievances that initiate from a variety of sources
• Ensures positive client relationships and meeting expectations regarding appeals processing
• Coordinates with various departments to ensure timely appeal responses
• Presents analysis and documentation for reviews in aggregate and interprets and identifies trends and opportunities for process and program improvements
• Continuously identifies opportunities to increase efficiency in workflows and operations for Appeals processes and staff
• Performs quality assurance monitoring of work performance for Appeals staff
• Monitors, mentors and provides performance feedback and evaluations for Appeals staff. Develops 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 closely with the Director of Appeal Operations to ensure the on-going implementation of new policies and procedures related to the QA process
• Attends, and leads as necessary, partner-facing/external calls to deliver updates on operations and solution with markets on identified needs

Benefits

• Healthcare that fits your needs
• 401(k) with Employer Match
• Generous Paid Time Off
• 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