Manager, Appeals
Coventry Health Care, a $12.2 billion Fortune 500 organization, is a national managed health care company with nearly 5.1 million members in all 50 states. At Coventry Health Care, we are driven to ensure that every person and organization we serve receives the greatest possible value for their health care investment. We do this by providing a full range of competitive products through our seven core businesses – Commercial Risk, Medicare Advantage, Medicare Part D, Medicaid, Workers' Comp Services, Federal Employees Health Benefits Plan and Network Rental.
We are committed to constantly improving our low-cost platform so that we can deliver the products and services that our customers want at a price they can afford. Coventry has the expertise, the experience, and the agility to craft the new products, the new processes, and the new service needed to make healthcare more accessible to all Americans.
We offer a competitive salary, excellent benefits (401K with company matching, comprehensive benefits including medical, dental, and tuition reimbursement), vacation and sick time. This is a highly visible role dealing with business partners across the division and corporation, and being a part of motivating a dynamic team!
Our national managed care company is seeking a Manager, Appeals in our Moon Township, PA Service Center. As a strategic member of the Customer Service Operations (CSO) leadership team, the successful candidate will be responsible for managing the appeals and grievance activities of a staff. Ensures compliance with all State and Federal regulations and national accrediting body requirements. We are looking for someone with a proven track record of growing and improving a department.
Qualifications:ESSENTIAL RESPONSIBILITIES
Responsible for the direct management of an appeals staff.
Responsible for compliance with State and Federal laws regarding the handling of appeals. Ensures
compliance with national accrediting body standards regarding grievances.
Ensures compliance with the applicable accreditation agency’s standard section regarding member rights
and responsibilities.
Produces all appeals and grievance reports. Researches customer information including applicable
medical records in response to difficult inquiries, including authorizations, payments, denials, and
coordination of benefits.
Assesses, investigates, and resolves difficult issues to achieve customer and member satisfaction when
possible. Receives all legal correspondence that is not directed to any specific individual.
Manages all complaints and inquiries for the Department of Insurance, legislators and elected officials.
May write and review policies to ensure compliance with all regulatory and applicable accreditation
agency’s requirements.
May work in conjunction with Legal Department to ensure all legal issues are addressed regarding
appeals.
Preparing for and assist with oversight of regulatory audits.
May identify, analyze, report, and insure implementation of all new and revised CMS and other applicable
compliance requirements related to quality improvement and new CMS coverage.
May ensure compliance and quality improvement through periodic oversight reviews of critical plan
processes. May assist in the development, implementation, and evaluation of quality improvement plans.
May develop and maintain quality improvement policies and procedures required by Federal contracts,
statutes and regulations. May review processes for continued improvement and efficiencies.
Recruits, develops, and motivates staff. Initiates and communicates a variety of personnel actions
including employment, termination, performance reviews, salary reviews, and disciplinary actions.
JOB SPECIFICATIONS
Bachelor’s degree or equivalent experience.
Licensed Registered Nurse preferred.
Previous (1-3 years) supervisory or project lead experience preferred.
Previous (1 – 2 years) Medicare experience preferred.
Experience in processing and working with Medicare Prescription Drug , Medicare Coordinated Care and Medicaid.
Expert knowledge of medical terminology required.
Knowledge of product specific regulations.
Ability to train employees on all products, procedures, and systems.
Other:
Highly self-motivated and able to work well under stress in a fast-paced environment.
Strong listening and interpersonal skills; skilled at developing and maintaining effective working relationships.
Demonstrated leadership and motivation skills.
Effective verbal and written communication skills.
Strong analytical and problem-solving skills.
Ability to train employees on all products and processes; ability to drive change.
Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: First/Mid Level Officials and Managers
Primary Location: Moon Township, PA, US
Organization: 10750 - Service Center - Central Admin
Schedule: Full-time
Job Posting: 2013-02-07 00:00:00.0
Job ID: 1310457