Appeals Manager

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🌲 North Carolina – Remote

🌲 North Carolina – Remote

💵 $67.6k - $90.5k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👔 Manager

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Trillium Health Resources

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

⚕️ Healthcare Insurance

Healthcare Insurance • Mental Health • Substance Use

Trillium Health Resources is a leading specialty care manager (LME/MCO) for individuals with serious behavioral health, intellectual/developmental disabilities, and traumatic brain injury in North Carolina. The organization is committed to investing in the health and well-being of the communities it serves, providing services such as preventive health screenings, crisis intervention, and tailored care management. Trillium focuses on enhancing access to mental health and substance use services for its members and ensuring support for vulnerable populations.

📋 Description

• Oversee and manage Trillium’s provider appeals processes. • Supervise provider appeals staff and evaluate the effectiveness/efficiency of the department through regularly scheduled individual staff supervision and staff meetings. • Interface with vendors and internal business units to ensure compliance and good communication across the department. • Research, read and interpret controlling authority (coverage policies and service definitions, State and federal statutes and regulations, applicable contracts, agency policies & procedures, etc.). • Oversee accurate and complete files for each appeal with all documents used in decision making. • Prepare files for audits and reviews, including, but not limited to, external quality reviews and accreditation reviews. • Support staff in drafting appeal resolution letters in accordance with practices established by the Legal Department and ensure all appeals are processed and completed timely within accordance with legal and contractual and accreditation standards. • Prepare reports for internal and external stakeholders.

🎯 Requirements

• Associate’s degree and three (3) years’ experience in appeals, performing research under the guidance of an attorney or Legal Department, conducting compliance and risk management activities, and drafting correspondence in accordance with practices established by an attorney or Legal Department; • OR Bachelor’s degree and minimum one (1) year experience in appeals, performing research under the guidance of an attorney or Legal Department, conducting compliance and risk management activities, and drafting correspondence in accordance with practices established by an attorney or Legal Department; • OR Equivalent combination of education/experience. • Must have a valid driver’s license. • Must reside within North Carolina. • Must be able to travel within catchment as required.

🏖️ Benefits

• Health Insurance with no premium for employee coverage • Flexible Spending Accounts • 24 days of Paid Time Off (PTO) plus 12 paid holidays in your first year • NC Local Government Retirement Pension (defined-benefit plan) • 401k with 5% employer match and immediate vesting • Public Service Loan Forgiveness (PSLF) qualifying employer • Quarterly stipend for remote work supplies