Appeals Manager

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🕒 vor 6 Tagen

🌲 North Carolina – Remote

🌲 North Carolina – Remote

💵 €67.632 - €90.457 / Jahr

⏰ Vollzeit

🟡 Mittelstufe

🟠 Senior

👔 Manager

Jetzt Bewerben

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Trillium Health Resources

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1001 - 5000 Mitarbeiter

⚕️ Krankenversicherung

Healthcare Insurance • Mental Health • Substance Use

Trillium Health Resources ist ein führender Spezialanbieter von Pflege-Management (LME/MCO) für Menschen mit schwerwiegenden Verhaltensstörungen, geistigen/entwicklungsbezogenen Behinderungen und Schädel-Hirn-Traumata in North Carolina. Die Organisation ist bestrebt, in die Gesundheit und das Wohlbefinden der Gemeinden, denen sie dient, zu investieren und bietet Dienstleistungen wie präventive Gesundheitsuntersuchungen, Krisenintervention und maßgeschneidertes Pflege-Management an. Trillium konzentriert sich darauf, den Zugang zu psychischen Gesundheits- und Substanzgebrauchsdiensten für seine Mitglieder zu verbessern und Unterstützung für gefährdete Bevölkerungsgruppen sicherzustellen.

Beschreibung

• 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.

🎯 Anforderungen

• 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.

🏖️ Vorteile

• 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