The Manager of Appeals & Correspondence is accountable for managing a team of employees to ensure compliance with standards set forth by National Committee for Quality Assurance (NCQA), Center for Medicare and Medicare Services (CMS), Maryland HealthChoice Program, State of Virginia Medicaid, and other State and Federal regulations and laws as it relates to appeals, complaints, grievances and regulatory inquiries.
Responsible for daily management of MAS' Appeals and Correspondence team. This includes work flow, work product quality and management of employees engaged in responding to member and provider appeals, grievances and concerns. Ensures adequate documentation and timeliness of appeal cases presented to the Appeals Committee.
Responsible for meeting all regulatory and accrediting agency requirements regarding documentation, timeliness and application of rules and procedures.
Identifies service gaps that contribute to member and provider dissatisfaction and are a source of unnecessary appeals cases or create employer group retention issues.
Serves as the department's key clinical liaison between MAS' Medical Group and UM Department. Also responsible for knowledge of Medicare and Medicaid standards and has accountability for the team complying with requirements.
Responsible for monitoring of compliance and quality, establishing individual and team performance measures, recruiting, hiring/terminating, conducting performance reviews, and rewards, and recognition.
Assist in the development of staff through coaching, counseling, and training; accountable for working within the union's guidelines when addressing non-compliant performance through corrective action.
Establishes and maintains effective communication with subordinate staff through regular staff meetings with the group to share information, and one-to-one interactions with individuals to discuss and review cases.
Serves as a member of the Appeals and Correspondence management team with accountability for tracking and monitoring caseload and ensuring implementation of processes and procedures of outcomes.
Develops, implements, and updates detailed procedures for the appeals process and correspondence with members; researches new or unusual issues and develops accurate and consistent responses to members and regulators.
Researches and responds to procedural and policy questions from appeals & resolution specialists, communication specialists and others.
With Director of Appeals and Correspondence participates in facilitating the activities of the Appeals Committee; participates in quarterly appeals meeting of committee members to address trends and or systemic issues identified during the appeals process.
Ensures all materials are present, organized and complete for all external and internal audits and reviews.
Minimum ten (10) years of work experience in health care.
Minimum five (5) years of people management experience.
Minimum three (3) years of NCQA, Medicare, Medicaid, Joint Commission or other health care compliance or regulatory experience.
Bachelor's in nursing, business administration/management, healthcare administration/management, economics, operations research, public health administration, human resources, education or call center management OR four (4) years of directly related experience is required.
High School Diploma or General Education Development (GED) required.
License, Certification, Registration
Strong critical thinking, analytical, negotiation, presentation, investigative and problem solving skills.
Excellent written and interpersonal communication skills.
Knowledge of medical terminology or HMO policy and procedures.
Strong customer focus for members and providers.
Strong proficiency in MS Excel and Word.
Demonstrated ability to determine the key business issues and develop appropriate action plans from multi-disciplinary perspectives.
Demonstrated ability to lead professionals through influence and collaboration.
Demonstrated ability to conduct and interpret quantitative/qualitative analysis.
Proven leadership skills in project management and consulting.
Must exhibit efficiency, collaboration, candor, openness, and results orientation.
Must demonstrate an understanding of the operations of KP, health policy trends, and any applicable regulations related to the responsible technical area.
Must be able to work in a Labor/Management Partnership environment.
Five (5) years of direct patient care experience.
Experience managing employees that are represented by a union.
Experience with CMS, Office of Personnel Management (OPM), Maryland Health Choice, Virginia Medicaid and the Mid-Atlantic region's State regulations governing healthcare organizations.
Durable Medical Equipment (DME) experience.
Master's degree preferred.
Knowledge of the Health Plan's Appeals & Grievances policies and procedures.
Primary Location: Maryland,Rockville,Rockville Regional Offices 2101 E.
Jefferson St.Scheduled Weekly Hours: 40Shift: DayWorkdays: Mon, Tue, Wed, Thu, FriWorking Hours Start: 8:30 AMWorking Hours End: 5:00 PMJob Schedule: Full-timeJob Type:
StandardEmployee Status: RegularEmployee Group/Union Affiliation: Salaried, Non-Union, ExemptJob Level:
Manager with Direct ReportsJob Category: Insurance / ClaimsDepartment: Appeals & CorrespondenceTravel:
Yes, 10 % of the TimeKaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status.
External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with federal and state laws, as well as applicable local ordinances, including but not limited to the San Francisco and Los Angeles Fair Chance Ordinances.
Click here for additional requirements >