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 Bachelors degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

Licenses / Certifications :

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 :

Knowledge, Skills and Abilities (KSAs)