Manager – Clinical Appeals and Grievances

🕒 Julho 29

🗽 New York, Tennessee, +2 estados a mais – Remoto

🗽 New York – Remote 🎸 Tennessee – Remote ⚔️ Virginia – Remote ⛰️ West Virginia – Remote

💵 $88.700 - $131.920 / ano

⏰ Tempo Integral

🟡 Pleno

🟠 Sênior

👔 Gerente

🦅 Patrocina Visto H1B

Esta empresa já patrocinou vistos H1B no passado.

👻 Score fantasma 18%

O que significa: quão provável esta vaga está aberta sem contratação ativa.Como ler: 60% ou mais significa que achamos que é uma vaga fantasma. Pontuações mais baixas preocupam menos.Como pontuamos: tempo em aberto, republicações, vagas abertas vs tamanho do time, rapidez para fechar vagas, e se o salário está divulgado.Observação: é uma estimativa de dados públicos, não um julgamento da empresa. Vagas reais podem ter pontuação alta, então use como uma dica, não como um fato.

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Healthfirst

SiteLinkedInTodas as Vagas

1001 - 5000 funcionários

Fundada em 1993

🛡️ Seguros

🏥 Saúde

⚕️ Seguro de Saúde

Insurance • Healthcare • Healthcare Insurance

A Healthfirst é uma provedora de seguros de saúde dedicada a ajudar os nova-iorquinos a acessar cobertura de saúde acessível para indivíduos e famílias. Com mais de 30 anos de experiência, a Healthfirst oferece uma variedade de planos, incluindo gerenciamento de cuidados do Medicaid, Medicare Advantage, cuidados de longo prazo e planos de saúde essenciais. A empresa foca em fornecer opções de saúde de qualidade, benefícios abrangentes e suporte para garantir que os membros possam manter sua saúde e bem-estar.

Descrição

• Lead, operate, and advise the Clinical Appeals & Grievances team • Work with organizational leaders to identify priority focus areas, standardize and optimize processes, and communicate performance to stakeholders • Oversee internal and external production teams to ensure consistent production, quality, and compliance • Manage specialists through goal and productivity management, coaching, counseling, and performance management • Provide oversight and advice in case research • Interpret health plan policies, procedures, and regulations to guide specialists • Ensure timely case resolution and make critical decisions, with focus on clinical criteria for expedited cases • Standardize and optimize Appeals and Grievances routing and deploy approaches to meet production, compliance, and quality targets • Establish departmental goals, monthly goal reviews, and action plans for identified gaps • Guide preparation of cases for Medical Director Review, ensuring complete investigation information • Oversee case preparation for Maximus Federal Services, Fair Hearing, and External Appeal throughout the appeal process • Assist in leading the AOR / WOL Outreach team • Educate providers with Providers and DSE on timely and accurate Appeals submissions • Maintain delegated vendor relationships and ensure vendor performance and compliance measures • Identify and execute process improvements across operational areas • Diagnose operational challenges and skill gaps and provide team leadership • Identify trends, recommend improvements, and drive development of tools, systems, and processes • Maintain knowledge of industry trends, best practices, and protocols and collaborate across the enterprise on enhancements

🎯 Requisitos

• Bachelor's degree from an accredited institution or equivalent work experience • RN • Experience with utilization management or appeals and grievance processing and compliance • Working experience in a fast-paced environment overseeing multiple priorities, tasks and/or teams • Proven track record of exercising independent thinking, ability to problem solve, understand process flows and correlating platforms to recommend and implement solutions • Experience preparing and delivering written and verbal information to multiple types of audiences • Demonstrated ability to build and foster effective relationships • Preferred: Experience in clinical practice with a focus in appeals & grievances, claims processing, utilization review or utilization management/case management • Preferred: Demonstrated understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, Milliman or Medicare local coverage guidelines • Preferred: Extensive experience in healthcare appeals • Preferred: MBA or master's degree from an accredited institution with focus in training & development, education, business, or healthcare administration • Preferred: Management experience in an operational department within the healthcare industry focused on clinical leadership • Preferred: Leadership experience in a focus area of operational excellence or audit • Preferred: Experience developing strategy and processes for a department or function • Preferred: Experience managing vendors as an extension of a core team • Preferred: Familiar with creating accountable ownership of a vendor team

🏖️ Benefícios

• Medical, dental and vision coverage • Incentive and recognition programs • Life insurance • 401k contributions