Manager – Appeal Operations

Position Summary:

At MedReview, our mission is to bring accuracy, accountability, and clinical excellence to healthcare. As such, we are a leading authority in payment integrity solutions including DRG Validation, Cost Outlier and Readmission reviews. We are seeking an Appeal Operations Manager with experience in Inpatient Hospital (On behalf of Payer) claims processing and the assignment of work within our appeals department.

The Manager of Appeal Operations oversees the appeal & Inquiry review process and management of the Appeals department staff. Monitors productivity and performance. Provides guidance and coaching to team as needed. The Manager of Appeal Operations assists Appeals leadership with training and orientation of all new employees and is responsible for oversight of the QA process within the department. This individual works collaboratively with Appeals leadership in developing and implementing Department policies and procedures related to quality improvement. The Manager of Appeals monitors QA data and provides a monthly QA analysis reflecting department productivity and error rates.

Candidate should be highly motivated, with strong Inpatient hospital payer appeals background. This individual must have excellent communication skills and an analytical mindset to achieve and maintain high-level performance in a fast-paced environment.

This is a fulltime position (40 hours per week) Monday – Friday. You’ll enjoy the flexibility to telecommute from anywhere within the United States. Training will be conducted virtually from your home.

Responsibilities:

This list does not represent all responsibilities for this position. Candidate must understand and be willing and able to assume roles and responsibilities other than these to meet the needs of the Appeals department and MedReview in general.

• Oversees workflow among employees to ensure maximum productivity and quality standards are met. Prioritize work to ensure completion of designated area responsibilities and functions
• Works collaboratively with the Appeal leadership to ensure claims are completed timely per the client’s SLA (service level agreement)
• Interface with Appeals Leadership regarding operational issues affecting the processing of claims
• Research as needed, escalated appeals or grievances that initiate from a variety of sources, including members, providers, state/federal regulators, and others within the timeframes outlined by federal and state regulations
• Ensure positive client relationships and meeting expectations regarding appeals processing
• Coordinate with various departments to ensure timely appeal responses
• Present analysis and documentation for reviews in aggregate and interpret and identify trends and opportunities for process and program improvements
• Continuously identify opportunities to increase efficiency in workflows and operations for Appeals processes and staff
• Perform quality assurance monitoring of work performance for Appeals staff
• Monitor, mentor and provide performance feedback and evaluations for Appeals staff. Develop action plan for low performers
• Assists with orientation and training of all new hires. Assists with the Development of training aids
• Supervises all QA activities regarding the work performed by team. Reviews all monthly QA reports prior to emailing. Monitors and records team productivity and error rates. Works collaboratively with the management team to develop a plan of action for employees with high error rates, low productivity
• Works closely with the Director of Appeal Operations to ensure the on-going implementation of new policies and procedures related to the QA process
• Attend, and lead as necessary, partner-facing/external calls to deliver updates on operations and solution with markets on identified needs
• Other duties as assigned
  
  

Requirements:

• Associate's degree in health information management, Business Administration or health related field or equivalent work experience is required
• 2+ years leadership experience in healthcare/health plan setting required
• 2+ years of appeals and grievances experience in a payer-based environment
• Proven operational excellence and building relationships across multiple teams
• Knowledge of HIPAA privacy information standards required
• Ability to prioritize and organize workloads and complete tasks independently
• Demonstrates excellence in written and oral communication including interpersonal skills
• Proficient knowledge of Microsoft Word, Excel and other business software
• Previous experience managing claims and/or claims appeals
• Knowledge of DRG validation review, cost outlier review and readmission review
• Knowledge of appeal requirements and regulations across Medicare/Medicaid businesses
• Knowledge of claim processing or claim auditing systems
• Knowledge of CMS (Medicaid/Medicare) regulations and requirements
• Ability to thrive in a fast-paced environment and manage multiple priorities
• Ability to coordinate multiple high priority issues while maintaining compliance and communication with clients
• Demonstrated strategic planning in a matrixed environment
• Strong quantitative and analytical problem-solving skills
• Detail oriented highly organized work skills
• Excellent computer skills
• Demonstrates the ability to motivate others
• Positive attitude who works well with others
• Willingness to improve workflow
  
  

Remote Work Requirements:

• High speed internet (100 Mbps per person recommended) with secured WIFI
• A dedicated workspace with minimal interruptions to protect PHI and HIPAA information
• Must be able to sit and use a computer keyboard for extended periods of time
  
  

Benefits and perks include:

• Healthcare that fits your needs - We offer excellent medical, dental, and vision plan options that provide coverage to employees and dependents
• 401(k) with Employer Match - Join the team and we will invest in your future
• Generous Paid Time Off - Accrued PTO starting day one, plus additional days off when you’re not feeling well, 11 observed holidays
• Wellness - We care about your well-being. From Commuter Benefits to FSAs we’ve got you covered
• Learning & Development - Through continued education/mentorship on the job and our investment in LinkedIn Learning, we’re focused on your growth as a working professional
  
  

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