Supv Appeals
The Supervisor of Appeals will lead a team of Appeal Specialists and Appeal Coordinators who process clinical and non-clinical appeals, and claim review requests, from all provider types, as well as clinical and non-clinical appeals and claim review requests from members. Ensures appeals are completed according to all regulatory standards as well as Corporate policies and procedures.
Responsible for ensuring that appeals processing is completed timely and accurately. Provide leadership, training, and assistance to direct reports that support the business goals of the Appeals team.
This position has a strong clinical focus. The successful candidate will have experience working with licensed clinicians at all levels and is comfortable explaining medical terminology and evaluating medical records.
Key Responsibilities:
· Ensures unit achievement of established performance, compliance, and quality metrics
· Coach, train, and develop staff to maximize team performance
· Develop desk procedures and streamline processes
· Drive operational efficiency and improve provider/member satisfaction
· Identify workflow gaps and recommend effective, actionable solutions
· Acts as a liaison with internal and external departments that interact daily with Provider Appeals
· Stays abreast of Claim Payment Policy & Medical Policy changes and communicate appeals impact
· Maintain a working relationship with associated Appeals teams and various business areas to serve as an Appeals SME and collaborate when cross-functional servicing is required
· Collaborates with various departments within the company, as well as third party vendors Legal, Compliance, Member Services, CMC, AIM, Medical Policy, Magellan, eviCore, and other departments to ensure appropriate appeal resolution.
· Analyze daily appeals reporting to ensure consistent servicing within the appeals team and identify trends
· Reviews management reports and controls unit inventory levels by monitoring volumes, productivity, and staffing on a daily basis; Identifies barriers and recommends solutions to the manager when process changes do not or cannot resolves issues
· Provide technical expertise related to Appeals applications and workflows
· Develop reporting for various adhoc requests
· Interviews, hires, provides ongoing feedback, recommends salary increases, and performance manages direct reports
· Able to intercede when sensitive appeals concerns arise and escalate, where appropriate
· Other duties as assigned
Education and Experience:
· Bachelor’s degree or equivalent experience ; prior experience in a leadership role preferred
· RN license highly preferred
· Minimum 5 years of progressive experience in a health care-related organization is required, with experience in Provider Networks, Contracting, Claims Processing or Managed Care
Operations strongly preferred.
· Excellent verbal and written communication
· Demonstrated ability to effectively utilize Microsoft office applications (Word, Excel, PowerPoint).
· Strong analytical and reporting skills
· Candidate must be able to work independently, manage multiple priorities effectively and have excellent analytical, organizational and problem solving skills.
· Proven ability to effectively interact with various levels of Management, is required.
Diversity, Equity, and Inclusion
At AmeriHealth, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.
About Our Company
Serving more than 8 million people nationwide, including 2.5 million in southeastern Pennsylvania, Independence Health Group — together with its subsidiaries — is the leading health insurance organization in the Philadelphia region. Our mission to build healthier lives for you, your family, and your employees shapes our actions and decisions every day.
At AmeriHealth, we see each of our members as an individual, with unique needs and concerns. We’re dedicated to harnessing the very latest ideas and technologies to deliver access to care that meets those needs and surpasses your expectations. For more information about Independence access our website at www.ibx.com. We’re revolutionizing health care, and our focus is on you!
Equal Employment Opportunity
AmeriHealth is an Equal Opportunity and Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.
Agency Disclaimer
All resumes submitted directly to an AmeriHealth employee from a vendor via email, the Internet or in any other form without a valid written search agreement in place for this position from the Independence Blue Cross Family of Companies Human Resources Department will be deemed the sole property of AmeriHealth and the Independence Blue Cross Family of Companies. Please note that no fee will be paid in the event the candidate is hired by AmeriHealth or the Independence Blue Cross Family of Companies as a result of the referral or through means other than our established process.