Clinical Appeals Supervisor (Hybrid)

Resp & Qualifications

PURPOSE:

The Clinical Appeals Supervisor directs and coordinates the accurate implementation of the grievance and appeals process for members and providers who appeal or file a grievance on behalf of members for Government Program lines of business. Develops, evaluates, and oversees implementation of procedures to include develop of job aides that result efficient operational workflows and quality resolution of the member and provider grievances and appeals regarding adverse coverage determinations in accordance with Federal and State mandates and NCQA accreditation standards. Directs the activities and serves as a resource for associates within the Government Program Appeals and Grievance department. We are looking for an experienced clinical leader 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 time at a CareFirst location based on business needs and work activities/deliverables that week.

ESSENTIAL FUNCTIONS:

• Provides direct supervision for the activities of assigned staff, ensuring appropriate and complete resolution of appeals and grievances, including Regulatory complaints and External review requests. Accountable for day-to-day operations ensuring timely triage, intake, and acknowledgement of grievances and appeals to comply with regulatory timeframes. Accountable for quality review and interpretation of the grievance and appeal cases and accurate and timely oral and written notification as required by Federal and State mandates and NCQA accreditation standards. Informs and educates internal stakeholders regarding medical facts and issues regarding appeal or claim payments. Acts as liaison and collaborates with attorneys and Medical Directors to prepare for legal proceedings and provide testimony on behalf of the company.

• Coordinates and/or conducts research, summarizes documentation and oversees the chronological presentation of plan handling to respond to regulatory complaints and to assist the Legal Department. Informs and educates corporate attorneys regarding facts and issues related to grievances and appeals. Acts as liaison and collaborates with interdisciplinary stakeholders to include Service Operations, Claim Operations, Utilization Management, Medical Directors and, when applicable, attorneys to prepare for legal proceedings and provide testimony on behalf of the company.

• Responsible for development of desk top procedures and job aids, onboarding checklists, and oversight of the orientation, training, and competency validation of new and current associates. Responsible for assessment of department training needs and ensures staff receive timely communication regarding regulatory updates that impact their work. Assigns tasks according to operational requirements taking into consideration the associates knowledge, skill sets, experience and development needs. Development, implementation and evaluation of performance plans, providing accurate and timely performance reviews and feedback. Monitors the monthly audits and productivity performance of associates and ensure adherence to same.

• Supports the Manager and Director in identification, research and coordinating a comprehensive response to problems, issues or concerns that have a cross functional impact throughout the company. Maintains a ready command of a continuously expanding knowledge base of current practices and procedures.

• Develops informative, educational and training presentation for internal and external stakeholders. Supports annual review of updated materials (e.g., handbooks, EOCs, ANOCs, etc.) to ensure all applicable Appeals & Grievance information is accurate. Escalates discrepancies to Manager, as needed. Supports the Manager of Clinical Appeals and Analysis in the development of quarterly, review, and compiling statistical performance data and data related to the volume and complexity of the appeals and grievances submitted for resolution.

SUPERVISORY RESPONSIBILITY:

This position manages people - 10-15.

QUALIFICATIONS:

Education Level: Bachelor of Science in Nursing or Bachelor's degree in a related health discipline.

Licenses/Certifications Upon Hire Required:

• RN - Registered Nurse - State Licensure And/or Compact State.

Experience : 5 years of experience in utilization management and/or appeals and grievances investigation and processing. Demonstrated leadership skills.

Preferred Qualifications:

• MSN Degree.

• 3 years leadership/supervisory experience.

• 3 years of Medicare/Medicaid appeals and grievance investigation and processing and/or payment/revenue/charge integrity.

• Basic coding knowledge (CPT/HCPCS, modifiers, MUEs, etc.).

• Basic claims processing knowledge (e.g., claim edits, EOBs, EOPs, reprocessing, etc.).

• Advanced typing skills, with the ability to talk and type simultaneously.

Knowledge, Skills and Abilities (KSAs)

• Demonstrated knowledge of regulatory and accreditation requirements, 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.

• Excellent analytical and problem-solving skills are needed to assess the medical necessity and appropriateness of patient care and treatment on a case-by-case basis.

• Must be able to evaluate demands on a timely basis, establish and manage multiple priorities, and respond appropriately to unplanned events/projects.

• Excellent verbal and written communication skills, strong listening skills, critical thinking and analytical skills, problem solving skills, ability to set priorities and multi-task in order to communicate effectively with internal and external customers.

• 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.

• 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: $82,800 - $170,775

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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REQNUMBER: 22491