Supervisor Appeals (Legal)

Our organization is looking for dynamic individuals who love to learn, thrive on innovation, and are open to exploring new ways to achieve our goals.  If this describes you, we want to speak with you. You can help us achieve our vision to lead nationally in innovating equitable whole-person health.

At Independence, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve. 

Supervises the administrative staff in the Appeals department to include finalizing appeal and inquiries within the confines of budgetary and compliance considerations.  Supports all lines of business for fully and self-insured members and providers, according to the regulatory and accreditation standards, contractual arrangements, and benefit plans.  Works with the management team and supervises daily activities of associates whose primary responsibilities are intake, triage, and review of administrative appeals.  Additionally, oversees generating and reviewing letters, daily productivity, and outreach to associates in other departments as needed.  Ensures appeals and inquiries are completed according to applicable regulatory and accreditation standards as well as and corporate timeliness requirements.

Responsibilities:

·        Provides expertise, leadership and technical support to the Appeals team.

·        Educates team as new procedures are developed, reviews procedures with staff as needed and monitors staff to ensure that procedures are implemented and adopted as standard practice.

·        Analyses daily workflow of Appeals Specialists to ensure cases are handled thoroughly and kept within compliance timeframes.

·        Supports timely and accurate work that includes: image tracking, dispute resolution, letter generation, appeal case creation appeals workflow management, and interaction with the clinical appeals team.

·        Determines which issues are appeals and the appropriate team to handle the work, the appropriate categorization of the appeals (expedited/standard, clinical/non-clinical, pre-service/post-service) according to regulatory/accreditation standards.

·        Provides initial research when requested by Appeals specialists, and routinely and consistently applies the administrative exception procedures.

·        Periodically conducts audits of closed appeals files for compliance with established process and identifies root causes for out of compliance cases.

·        Reviews management reports and controls unit inventory levels by monitoring volumes, productivity and staffing on a daily basis.  Identifies barriers and recommends solutions to the manager when process changes do not or cannot resolve the issues.

·        Assures processes are in place for timely and accurately delivery of appeal outcomes.

·        Oversees the file management responsibilities of the appeals department.  Establishes and oversees procedures to ensure that member files are secured according to corporate record retention guidelines and archived according to standards.

·        Manages analyses and reports on appeal compliance. 

·        Ensures letter templates are kept current and works with the Business Analysts to make changes when necessary.

·        Monitors the effectiveness of appeals documentation in various business systems. 

·        Performs Audits on letters sent out by direct reports to ensure reader-friendliness, professionalism, consistency with NCQA requirements.. 

·        Monitors the accuracy of data entry and appeals classification.

·        Collaborates with various departments within the company to ensure appropriate appeal resolution.

·        Develops and documents processes and procedures including Best Practices to assure consistency of the investigation and resolution process. 

·        Provides education to the team as new procedures are developed.

·        Reviews procedures with staff as needed and monitors staff to ensure that procedures are implemented and adopted as standard practice.

·        Performs other duties as assigned.

 

Qualifications:

·        Bachelor's degree with 3 years' experience in an appeals setting.

o    In lieu of degree 5 years experience in Member services, Provider Services, Claims, Appeals or equivalent. Prior leadership experience preferred.  Demonstrated excellent leadership, organizational interpersonal, written and verbal communications skills required.  Ability to prioritize work and analyze workflows.  Must be able to work independently and as part of a team.  Must excel at motivating, coaching and counseling others.

 

Independence Blue Cross is an Equal Opportunity and Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.

 

Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app.