Clinical Appeals Manager (Hybrid)

Resp & Qualifications

PURPOSE:

This role manages the appeal process for members and providers who appeal on behalf of members for government program lines of business. Ensures quality management of the clinical appeal process to reduce the risk of State and Federal Regulatory fines and sanctions, avoid adverse exposure, reiterate the expectation of a fair and compliant appeal process for our membership, and support NCQA accreditation and the Divisional Goals for Health Services. Ideal candidate will have minimum of three years of government program (Medicare/Medicaid) appeal and grievance operational oversight. We are looking for an experienced professional in the greater Baltimore metropolitan area who is willing and able to work in a hybrid model. The incumbent will be expected to work a portion of their week from home and a portion of their week at a CareFirst location based on business needs and work activities/deliverables that week.

ESSENTIAL FUNCTIONS:

• Develops, establishes and implements a compliant appeal process with dynamic goals resulting in the full and fair review of appeals and designed to achieve corporate objectives and advance departmental capabilities. Accountable for ensuring that appeal decisions are accurate based on the member''s health benefit contract and CareFirst Medical Policy and are compliant with State, Federal requirements and accreditation standards. Ensures appropriate and complete resolution of appeals, Regulatory complaints and External review requests. Performs analytics and research to promote best practices, problem solve, facilitate resolution and effectively integrate new processes.
• Develops, implements, and monitors associate performance standards and resulting documentation to ensure compliance with State, Federal requirements and NCQA standards for all functions within the scope of this position. Manages the tracking, trending, and data analysis of the end-to-end appeal experience and takes appropriate action based on the findings. Manages standardized and ad hoc reporting requirements including but not limited to annual and semi-annual reports to Committees, and Regulatory Agencies.
• Proactively involved in the review, interpretation and implementation of new legislation that impacts Health Services. Provides support to Legal which includes evaluating, analyzing and rendering informed opinions regarding the delivery of health care and the resulting outcomes including but not limited to the preparation of chronologies of medical events in response to regulatory complaints and/or to assist the Legal Department in preparation for legal disputes including attending and testifying on behalf of the Company. Prepares and participates in appropriate and assigned presentations and educational/operational meetings. Supports Director in reviewing and updating policies, standard operating and desk top procedures.
• Ensure compliance with Regulatory filings, as required. Professionally engages and interacts with internal and external business partners, and Regulatory and Accreditation Agencies, regarding the appeal process.
• Manages the day-to-day activities for appeal management including managing, coaching, and guiding associates in order to implement departmental, divisional, and organizational mission/goals. Develops annual goals, and prepares, monitors, and analyzes variances of departmental budgets in order to control and appropriately allocate resources.

SUPERVISORY RESPONSIBILITY:

This position manages people.

QUALIFICATIONS:

Education Level: Bachelor''s Degree in Nursing, Social Work, Health Care Administration or related discipline OR in lieu of a Bachelor''s degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

Licenses/Certifications:

• RN - Registered Nurse - State Licensure And/or Compact State Licensure Upon Hire Required or
• LCSW- License Clinical Social Worker Upon Hire Required
• CCM - Certified Case Manager Upon Hire Preferred or
• LNCC - Legal Nurse Consultant Certified Upon Hire Preferred

Experience:

• 5 years Experience in a managed care operational environment; and/or State or Federal appeal management.
• 1-year Supervisory experience or demonstrated progressive leadership experience

Preferred Qualifications:

• Ideal candidate will have minimum of three years of government program (Medicare/Medicaid) appeal and grievance operational oversight.
• Three years supervisory or demonstrated progressive leadership experience. Master''s in Science Nursing or related field, Legal Nurse Consultant, Certified Case Manager.

Knowledge, Skills and Abilities (KSAs)

• Demonstrated knowledge of regulatory requirements and accreditation standards, understanding of appeals process and utilization management, and systems software used in processing appeals.
• Knowledge and understanding of medical terminology.
• Understanding of the appeals process and ability to work independently in researching complex issues.
• Ability to mentor and coach associates to accomplish goals, provide objective evaluation of associate performance, and implement strategies to improve individual and team-based performance as needed.
• Exhibits interest in an understanding of health economics. Embraces the corporate mission to ensure access to affordable care and applies clinical knowledge and skills with the business operations framework.
• Ability to communicate effectively and work with teams.
• Effective presentation, negotiation and influencing skills to interface with all levels of management.
• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

Salary Range: $99,920 - $185,477

Salary Range Disclaimer

The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate''s work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case''s facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Federal Disc/Physical Demand

Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

PHYSICAL DEMANDS:

The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship

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