Appeals Supervisor Job Description
Appeals Supervisor Duties & Responsibilities
To write an effective appeals supervisor job description, begin by listing detailed duties, responsibilities and expectations. We have included appeals supervisor job description templates that you can modify and use.
Sample responsibilities for this position include:
Appeals Supervisor Qualifications
Qualifications for a job description may include education, certification, and experience.
Education for Appeals Supervisor
Typically a job would require a certain level of education.
Employers hiring for the appeals supervisor job most commonly would prefer for their future employee to have a relevant degree such as Bachelor's and Associate Degree in Education, Nursing, Healthcare, Law, Business, Management, Health, Health Care, Technical, Science
Skills for Appeals Supervisor
Desired skills for appeals supervisor include:
Desired experience for appeals supervisor includes:
Appeals Supervisor Examples
Appeals Supervisor Job Description
- Provides expertise, leadership and technical support to the Medicare Appeals and Grievances and teams
- Educates team as new procedures are developed, reviews procedures with staff as needed and monitors staff to ensure that procedures are implemented and adopted as standard practice
- Leads efforts for associate engagement, development and other essential administrative tasks
- Analyzes daily workflow of Appeals Specialists and Team leaders to ensure cases are handled thoroughly and kept within compliance timeframes
- Reviews management reports and controls unit inventory levels by monitoring volumes, productivity and staffing on a daily basis
- Identifies root causes for out of compliance cases and establishes corrective action plans
- Identifies barriers to success, develops recommendations and participates in implementation
- Clarifies benefit interpretation and collaborates with Member Services, Benefits, Legal, Compliance, Marketing, Enrollment, CMC, Medical policy, AIM, Magellan and other areas to report and resolve issues related to Appeals and Grievances
- Collaborates with staff to ensure that established productivity, timeliness and accuracy standards are attained in accordance with Corporate, NCQA, State and Federal standards
- Participates with Member Appeals management team in the planning and modification of the appeals process
- Set in a high-volume, fast-paced office environment
- Responsible for the support of weekend staff including holidays and other days that the office is closed
- Participation in Corporate, External and CMS audits of Appeals and Grievance Cases
- Bachelor’s Degree preferred and 3 years of experience in a customer setting or equivalent
- In lieu of degree, 5 years of experience in Member Services, Provider Services, Claims, Complaint handling or equivalent
- Prior experience in Member Appeals preferred
Appeals Supervisor Job Description
- Develop policy and procedures performance standards by which to monitor the department’s progress
- Recruit, interview, and hire staff based on candidate’s qualifications
- Interact effectively with BCBST personnel within medical management, operations, Provider Networks and Contracting, and executive management external members and providers
- Review and monitor all high dollar appeals for accuracy and appropriateness
- Ensure accuracy and timeliness of all escalated appeals
- Complete action required for escalated account workflow pools
- Monitor high balance account pools to ensure acceptable inventory levels
- Provide department-based training and support
- Conduct department quality reviews
- Maintain training and reference material on SharePoint site
- Demonstrated excellence in prior leadership role/s
- Demonstrated organizational, interpersonal, written and verbal communication skills required
- Ability to prioritize work and analyze workflows
- Demonstrate strong skills in use of Highmark and PBM systems
- Must have good organization skills and be able to prioritize
- Must excel at motivation, coaching and counseling others
Appeals Supervisor Job Description
- Participate on facility denial calls/lead calls as needed
- Support department report production
- Provide first level review and approval of adjustment transactions
- Review facility/payer based issues identified and maintain department issues log
- Lead special inventory projects as assigned
- Approve and enter time exceptions/updates in Kronos
- Monitor team attendance
- Provide team members with routine feedback on individual quality and productivity performance
- Provide coverage for coordinators and appeal specialists during vacation/leaves
- Manages staff and operations
- Minimum 5 years of demonstrated medical management, or operational experience or clinical experience (if RN) required
- Minimum 2 years of managed care experience, or experience with regulatory or accrediting body requirements (i.e., NCQA, URAC, EQRO, CMS, TennCare) required
- Minimum 2 years supervisor experience or previous experience leading a team or directing the work of others required
- Personal computer operation with skills in various software applications, including word processing, spreadsheets, electronic mail and presentation programs
- Extensive product, distribution and Claims industry knowledge
- Microsoft Office tools (Outlook, Excel, Word)
Appeals Supervisor Job Description
- Manage the Appeals Team Inbox, including coordination of call assignments to appropriate appeals
- Coordinator and monitor volume of all calls in the queue
- Serve as back-up to the Doctor Review Inbox, including coordination of call assignments to appropriate Physician Advisor Reviewers and monitor volume of all calls in the queue
- Support Manager of Appeals for all appeal documents related to new implementations, including testing to ensure that all documentation related to new implementations are accurate and meeting quality standards
- Provide direct guidance to company and contractor employees by supervising, motivating, and monitoring staff to ensure compliance with appeals procedures and standards
- Oversee workflow management of approved processes
- Accomplish staff results by communicating job expectations and planning, monitoring, and appraising job results, coaching and counseling employees
- Utilize control systems and procedures to maximize productivity
- Complete special projects by organizing and coordinating information and requirements planning, arranging and meeting schedules
- Perform reopening’s and all essential post-adjudication responsibilities
- Hospital patient accounting and billing systems
- LPN or RN with current license to practice required
- Several years’ of clinical nursing experience required
- Bachelor’s degree in healthcare, business, or related field preferred
- Couple years’ of experience supervising non-exempt, hourly staff strongly preferred
- May require department-specific license, certifications and/or designations
Appeals Supervisor Job Description
- Manage Administrative Law Judge (ALJ) activities for Part C including participating in hearings as necessary
- Ensures coverage dispute reconsideration meet applicable quality standards
- Reviews and Updates Part C specific Policy materials as appropriate and documents
- Represents the Part C QIC on the QIC Change Control Committee
- Key participant in CMS Medical Forums and Project Audits
- Participates in ALJ (Administrative Law Judge) hearings to explain and defend reconsideration decisions
- Responds to outside inquiries of concerns regarding decided reconsidered determinations
- Performs special projects not related to a specific case such as general legal research
- Daily operational oversight, staff development, budget management, audit readiness, staff training documentation and execution and policy and procedure documentation
- Work with internal partners and the PA staff to ensure ability to service physicians, pharmacists and patients within service levels and provide for appropriate clinical drug therapies
- 1 or more years of clinical appeals experience
- Bachelor Degree and 2 years business experience OR 6 years business experience
- 3 years appeals review experience
- Unrestricted, current Registered Nurse licensure required
- Minimum five years of progressively responsible experience in an acute care/clinical setting, including utilization management, case management, appeals and/or discharge planning
- Three years of experience within utilization management in a managed care organization required