Appeals Manager Job Description
Appeals Manager Duties & Responsibilities
To write an effective appeals manager job description, begin by listing detailed duties, responsibilities and expectations. We have included appeals manager job description templates that you can modify and use.
Sample responsibilities for this position include:
Appeals Manager Qualifications
Qualifications for a job description may include education, certification, and experience.
Licensing or Certifications for Appeals Manager
List any licenses or certifications required by the position: FEMA, CPC, MCG, CCS, AAHAM, SAS, SQL, RHIA, TQM
Education for Appeals Manager
Typically a job would require a certain level of education.
Employers hiring for the appeals manager job most commonly would prefer for their future employee to have a relevant degree such as Bachelor's and Collage Degree in Education, Healthcare, Performance, Nursing, Law, Business, Management, Health, Associates, Graduate
Skills for Appeals Manager
Desired skills for appeals manager include:
Desired experience for appeals manager includes:
Appeals Manager Examples
Appeals Manager Job Description
- Sets team direction, resolves issues and provides guidance to team ensuring policy and procedures are appropriately followed
- Collaborates cross-functionally with key business stakeholders to meet service level agreements, resolve issues, and partner on improvement opportunities
- Identifies and implements quality and process improvements to maximize efficiencies
- Monitors, trends and analyzes grievance denials, and appeals data for submission to appropriate parties
- Serves as clinical resource expert and mentor to unit and other departments for complex issues and interpretation of regulatory standards
- May perform internal audits of grievance, denials, and appeals process
- Performs internal audits of grievance, denials, and appeals process
- Reviews prospective or retrospective medical records of denied services for medical necessity
- Serves as subject matter expert for team and works on projects impacting development, interpretation, and implementation of medical policy or other managed care initiatives that may cross functional lines or sta
- Manage daily activities and inventory related to SSC Appeals function, ensuring processes are performed accurately, efficiently and effectively within all established operational and SOX guidelines
- Medical management process
- Company's internal business processes
- Microsoft Office Products (Word, Excel, and Outlook)
- Minimum of five years’ recent acute care experience with medical-surgical/critical care preferred
- Utilization and/or Case Management experience recommended
- Comprehensive knowledge and application of InterQual® preferred
Appeals Manager Job Description
- Coordinate with all necessary departments related to contract issues
- Perform QA for all processes within Appeals
- Work as a liaison between the Appeals staff and other SSC staff
- Resolve issues escalated by Appeals staff
- Closely monitors and leads ongoing review of Appeals & Grievances metrics, performance, improvements, and issues with business partners and A&G teams
- Conducts root cause analysis on appeals that contribute to decrease in performance and failure to meet commitments to understands reasons for not meeting state requirements, developing action plans to address the issues / gaps with the cross functional teams
- Provides support and coordinates with UHC Benefit Operations for any A&G needs in audits or regulatory inquiries
- Supervise a team of Student Appeals Officers and one FTE Office Specialist
- Provide continuing training to Student Appeals Officers to ensure department and university goals are met
- Prepare work schedules student workers
- Certified Case Manager (CCM) or Certified Professional in Utilization Review/Utilization Management/Healthcare Management (CPUR , CPUM, or CPHM) preferred
- Health insurance experience is highly preferred
- Lead point of contact for PTS employees for In Contact questions
- Send Dean’s Referrals when necessary
- Provide in person customer service to customers who are disputing citations
- Handle all Salesforce cases pertaining to appeals
Appeals Manager Job Description
- Process appeal requests as necessary
- Attend a weekly customer service meeting to communicate information relating to appeals
- Perform account maintenance in Flex
- Complete MVD searches to help identify customers and assign citations
- Educate customers on reasons they are receiving citations and how to remedy the situation
- Collaborate with Dispatch to resolve customer issues
- Send Certified Letters when needed
- Process all refunds pertaining to Appeals
- Process void requests by other PTS departments
- Coordinate recruitment to include processing requests for hires, screening applicants, participating in the interviewing process
- Develop and schedule program work plan in accordance with specifications
- Participate in and oversees Tabling Events such as New Employee Orientation, New Student Orientation and other tabling events providing information, interacting with patrons, ensuring sufficient staffing needs are met, ordering giveaways, and setting up venue
- Oversee projects in the Customer Service area
- Prepare periodic reports on program activities, progress, status or other special reports for management
- Develop, compile, and write communications related to Appeals
- Interact and maintain liaison with students, faculty and staff
Appeals Manager Job Description
- Conducts Case Management compliance trend analyses from system reports, identifies gaps, and develops program components to mitigate identified gaps
- Conducts appeal and denial reviews and trend analysis from various sources, such as audit reports, RAC/MAC trackers, and other appeal and denial information to assist in revising the appeal and denial processes to ensure optimum patient outcomes with appropriate utilization of services
- Provides ongoing evaluation and assessment of Facility practices and industry changes to ensure the enterprise remains current in processes related to appeals and denials
- Partners with Division Managed Care Department to engage with different payors to provide feedback regarding trends and issues
- Engages with individual facilities to identify unique concerns and assists with development of action plans
- Conducts ongoing research to remain current in evidence-based best practices
- Maintains and articulates current knowledge and understanding of all corporate policies and procedures related to job function
- Oversees the unit and staff members reviewing disability and workers compensation claims
- Makes recommendations on training needs
- Ensures effective process management
- Demonstrated knowledge of and practical application of Conflict Resolution methods
- Experience in customer service (1 year)
- Experience in marketing and outreach 1 year)
- Four years of supervisory experience or prior experience supervising a student workforce in a higher education setting
- Experience in organizing works activities and people
- Evidence of effective verbal and written communication skills (i.e., accurate grammar and spelling)
Appeals Manager Job Description
- Generates reports of denial activity on a monthly basis with analysis of data and significant trends to the leadership team Perform retrospective record reviews providing clinical updates to insurer in a timely manner
- Serve as a resource to Finance, Patient Access, Coding, Patient Accounts and various clinical departments in clarifying hospital status for specific accounts
- Perform prebill audits on all inptatient stays that do not meet the 2 midnight rule and assure the proper level of care
- Develop and track indicators and report trends to Director and CFO
- Strategic design and implementation of Quality Improvement process and infrastructure, policies, procedures, workflows
- Directs all quality training activities
- Direct the daily Medicare appeals and grievance activities to ensure best in class resolution and service ensure compliance with policies, procedures and regulation
- Responsible for day to day activities, Management and oversight of Technical Denials Appeal department - this includes ensuring communication to team on overall communication on projects, activities, goals and metrics related to department and within the larger AR
- Responsible for Inventory management - ensuring adherence to monthly goals and documentation and action plans to goals when unable to meet
- Manage levels of performance and assist with employees’ professional growth by planning and building an effective organization
- Experience in T2 Flex (1 year)
- Experience in Sale Force (1 year)
- Maintains call tracking system of correspondence and outcomes for Providers appeals/grievances
- Experience reviewing all types of medical claims
- 3-5 years acute care case management experience required
- Denials and Appeals Management experience required