Supervisor Appeals Management

Northwell Health Melville , NY 11747

Posted 2 months ago

Job Description:

Supervises and oversees the operations of the centralized appeals process for the Health System. Perform quality audits on appeal cases. Facilitates the even work-flow to maintain timely response to appeals.


  • Supervises, hires, trains, disciplines and evaluates the performance of staff.

  • Ensures performance appraisals on inpatient auditors are completed in a timely manner.

  • Provides training to new employees.

  • Performs monthly quality reviews on staff. Identifies, evaluates and implements opportunities for efficiencies.

  • Plans, organizes, coordinates and evaluates staffing requirements to meet operational goals.

  • Assigns and schedules direct reports to ensure smooth and efficient workflow.

  • Promotes staff development and education by providing opportunities for formal and informal education to promote competency.

  • Develops and performs staff educational programs. Ensures staff completes annual training.

  • Maintains data tracking systems and provides reports to Patient Accounts, Director of Case Management, Medical Director and Quality Management staff.

  • Sets performance standards and provides ongoing feedback to staff.

  • Generates department metrics.

  • Reports operational performance, justification and/or corrective action.

  • Oversees and coordinates appeals process.

  • Reviews and evaluates cases denied by all Third Party payers and determines follow through for level of appeals. Assigns cases to staff, as appropriate.

  • Monitors inpatient denials and assists patients and physicians with management of the appeals process.

  • Performs related duties, as required.

  • ADA Essential Functions

Qualifications

  • Bachelor's Degree in Nursing, required. Master's Degree, preferred.

  • Current license to practice as a Registered Professional Nurse in New York State.

  • Minimum of five (5) years clinical experience, plus a minimum of two (2) years experience in case management/utilization management/discharge planning and third party payment systems.

  • Maintains current knowledge of all IPRO, Managed Care and Third Party Review requirements.

In-depth knowledge of the appeals and denial processes; strong communications skills and computer literacy.


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VIEW JOBS 12/8/2018 12:00:00 AM 2019-03-08T00:00 Job Description Supervises and oversees the operations of the centralized appeals process for the Health System. Perform quality audits on appeal cases. Facilitates the even work-flow to maintain timely response to appeals. * * * * * Supervises, hires, trains, disciplines and evaluates the performance of staff. * Ensures performance appraisals on inpatient auditors are completed in a timely manner. * Provides training to new employees. * Performs monthly quality reviews on staff. Identifies, evaluates and implements opportunities for efficiencies. * Plans, organizes, coordinates and evaluates staffing requirements to meet operational goals. * Assigns and schedules direct reports to ensure smooth and efficient workflow. * Promotes staff development and education by providing opportunities for formal and informal education to promote competency. * Develops and performs staff educational programs. Ensures staff completes annual training. * Maintains data tracking systems and provides reports to Patient Accounts, Director of Case Management, Medical Director and Quality Management staff. * Sets performance standards and provides ongoing feedback to staff. * Generates department metrics. * Reports operational performance, justification and/or corrective action. * Oversees and coordinates appeals process. * Reviews and evaluates cases denied by all Third Party payers and determines follow through for level of appeals. Assigns cases to staff, as appropriate. * Monitors inpatient denials and assists patients and physicians with management of the appeals process. * Performs related duties, as required. * ADA Essential Functions Qualifications * Bachelor's Degree in Nursing, required. Master's Degree, preferred. * Current license to practice as a Registered Professional Nurse in New York State. * Minimum of five (5) years clinical experience, plus a minimum of two (2) years experience in case management/utilization management/discharge planning and third party payment systems. * Maintains current knowledge of all IPRO, Managed Care and Third Party Review requirements. In-depth knowledge of the appeals and denial processes; strong communications skills and computer literacy. Northern Westchester Hospital Melville NY

Supervisor Appeals Management

Northwell Health