Clinical Appeals Manager; Hybrid

Resp & Qualifications

PURPOSE:

This role manages the appeal process for members and providers who appeal on behalf of members for Commercial 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 Care Management.

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 week from home and a portion of their week at a Care First location based on business needs and work activities/deliverables that week.

• 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 Care First Medical Policy and are compliant with State, Federal and accreditation requirements. 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 and NCQA requirements 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.
• Ensure compliance with regulatory filings, as required, to maintain Private Review Agent Certifications. Professionally engages and interacts with internal and external business partners, and regulatory 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.

This position manages people.

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.

• RN - Registered Nurse - State Licensure And/or Compact State Licensure (Upon Hire Required)
• CCM - Certified Case Manager (Upon Hire Preferred or)
• LNCC - Legal Nurse Consultant Certified (Upon Hire Preferred)

• 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.

• 3 years supervisory or demonstrated progressive leadership experience. Master's in Science Nursing or related field, Legal Nurse Consultant, Certified Case Manager.

• 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.
• 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…