Clinical Appeals Supervisor (Hybrid)

Clinical Appeals Supervisor

The Clinical Appeals Supervisor directs and coordinates the accurate implementation of the clinical appeal process for members and providers who appeal on behalf of members for Government Programs lines of business. Develops, evaluates and oversees the implementation of policies and procedures that result in quality resolution of member and provider disputes regarding adverse and adverse coverage determinations in accordance with Federal and State mandates. Directs the activities and serves as a resource for associates within the Appeals and Grievances Department for Government Programs. We are looking for an experienced clinical leader in the greater Baltimore metropolitan area who is willing and able to work in a hybrid model. The incumbent will be expected to work a portion of their week from home and a portion of their week at a CareFirst location based on business needs and work activities / deliverables that week.

Essential Functions :

Provides direct supervision for the activities of assigned staff, ensuring appropriate and complete resolution of appeals and reconsiderations, including Regulatory complaints and External review requests. Accountable for quality review and interpretation of the appeal case and accurate communication of the appeal decision, including all applicable External review rights. Acts as the primary professional resource to internal and external stakeholders with the overall goal of providing and ensuring appropriate and timely response to Regulatory complaints and appeals.

Coordinates and / or conducts research, summarizes medical documentation and oversees the chronological presentation of plan handling to respond to regulatory complaints and to assist the Legal Department. Informs and educates corporate attorneys regarding medical facts and issues relating to appeals or claims payment. Acts as a liaison and collaborates with attorneys and Medical Directors to prepare for legal proceedings and provide testimony on behalf of the company.

Responsible for development and oversight of the orientation and training of new and current associates, and assessment of department training needs. Assigns tasks according to associate knowledge, skill sets, experience and development needs. Development, implementation and evaluation of performance plans, providing accurate and timely performance reviews and feedback. Monitors the monthly audits and productivity performance of associates.

Responsible for identification, research and coordinating a comprehensive response to problems, issues or concerns that have a cross functional impact throughout the company. Maintains a ready command of a continuously expanding knowledge base of current medical practices and procedures, including current medical, mental health and substance abuse / addiction procedural terminology, surgical procedures, dental procedures, diagnostic entities and their complications.

Develops informative, educational and training presentations for internal and external stakeholders. Supports the Manager of Clinical Appeals and Analysis in the development and presentation of quarterly reviews, compiling statistical performance data and data related to the volume and complexity of the appeals and grievances submitted for resolution.

Supervisory Responsibility :

This position manages people.

Qualifications :

Education Level : High School Diploma or GED OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

Licenses / Certifications :

RN - Registered Nurse - State Licensure And / or Compact State Licensure Upon Hire Required.

CCM - Certified Case Manager Upon Hire Preferred.

LNCC - Legal Nurse Consultant Certified Upon Hire Preferred.

Experience : 5 years medical-surgical or similar clinical experience OR 5 years' experience in Medical Review, Utilization Management or Case Management at CareFirst BlueCross BlueShield, or similar Managed Care organization or hospital. Demonstrated leadership skills.

Preferred Qualifications :

BS / MSN Degree.

Government Programs Appeals & Grievances experience.

Experience working in Guiding Care and Facets platforms, as well as utilizing MCG guidelines.

Knowledge, Skills and Abilities (KSAs)

Demonstrated knowledge of regulatory and accreditation requirements, understanding of appeals process and utilization management, and systems software used in processing appeals.

Knowledge and understanding of medical terminology.

Understanding of the appeals process and ability to work independently in researching complex issues.

Excellent analytical and problem solving skills are needed to assess the medical necessity and appropriateness of patient care and treatment on a case-by-case basis.

Must be able to evaluate demands on a timely basis, establish and manage multiple priorities, and respond appropriately to unplanned events / projects.

Excellent verbal and written communication skills, strong listening skills, critical thinking and analytical skills, problem solving skills, ability to set priorities and multi-task in order to communicate effectively with internal and external customers.

Ability to mentor and coach associates to accomplish goals, provide objective evaluation of associate performance, and implement strategies to improve individual and team-based performance as needed.

Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

Salary Range : $78,696 - $162,311

Salary Range Disclaimer

The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education / training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs / plans, and 401k contribution programs / plans (all benefits / incentives are subject to eligibility requirements).

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Physical Demands :

The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, @type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.

Sponsorship in US :

Must be eligible to work in the U.S. without Sponsorship