Appeal Resolution Supervisor jobs in California
Appeal Resolution Supervisor supervises a team responsible for the processing of appeals. Assigns and prioritizes cases. Being an Appeal Resolution Supervisor responds to and resolves escalated issues. Coaches and trains team in the utilization of industry standards and best practices. Additionally, Appeal Resolution Supervisor requires a bachelor's degree. Typically reports to a manager. The Appeal Resolution Supervisor supervises a small group of para-professional staff in an organization characterized by highly transactional or repetitive processes. Contributes to the development of processes and procedures. To be an Appeal Resolution Supervisor typically requires 3 years experience in the related area as an individual contributor. Thorough knowledge of functional area under supervision. (Copyright 2024 Salary.com)
Recently Added Appeal Resolution Supervisor jobs
Grievance & Appeal Lead/Supervisor
- Verda Healthcare
-
Huntington, CA
FULL_TIME
-
Verda Healthcare, Inc has a contract with the Center of Medicaid and Medicare Services (CMS) and Texas Department of Insurance for a Medicare Advantage Prescription Drug (MAPD) plan for 2024. We are looking for a Grievance & Appeal, Lead/Supervisor to join our growing company with many internal opportunities.
Are you ready to join a company that is changing the face of health care across the nation? Verda Healthcare, Inc is looking for people like you who value excellence, integrity, caring and innovation. As an employee, you’ll join a team dedicated to improving the lives of our Medicare members. Our vision incorporates value-based health care that works. We value diversity.
Align your career goals with Verda Healthcare, Inc and we will support you all the way.
Position Overview
The Grievance & Appeal Supervisor/Lead responds to written/verbal grievances, complaints, appeals and disputes submitted by members and providers: Review , analyze, research, resolve and respond to all types, in accordance with guidelines established by CMS and other regulatory agencies, where applicable, as well as internal policies. Will work with Clinical department regarding appeals related to Clinical policy. Work as an effective interface between internal and external customers. Maintain good member and provider relations.
Job Responsibilities- Review and evaluate appeal and grievance request to identify and classify member and provider appeals, hand-off to appropriate department for provider and clinical appeals; process member and provider complaints as appropriate to meet the CMS, State and Accreditation requirements.
- Determine eligibility, benefits, and prior activity related to claims, payment or service in question.
- Review research performed by operational areas to ensure the appropriate resolution to the appeal/grievance has been achieved, review contracts, member materials, medical payment policies, and provider education documents in researching and deciding the outcome of appeals.
- Accountable for appropriate review and determination in compliance with state and federal regulations.
- Conduct thorough investigations of all member and provider correspondence by analyzing all the issues involved and obtaining responses and information from internal and external entities.
- Perform comprehensive research related to the facts and circumstances of a member complaint, to include appropriate classification as a grievance, appeal, or both, in accordance wit regulatory requirements.
- Research appeal files for completeness and accuracy and investigate deficiencies. Consult with internal areas as required (such as the Legal Department) to clarify legal ramifications around complex appeals.
- Provide written acknowledgement of member and provider correspondence, prepare written responses to all member and provider correspondence that appropriately address each complaint’s issues and are structurally accurate.
- Follow-up with responsible departments to ensure compliance.
- Responsible for making verbal contact with the member or authorized representative during the research process to further clarify, as needed, for the member’s complaint.
- Ensure documentation requirements are met create and document service requests to track and resolve issues; document final resolutions along with all required data to facilitate accurate reporting, tracking and trending.
- Provide all follow up documentation of outcome to practitioners, providers, and members.
- Responsible for the timely, complete, accurate documentation of the appeal and/or grievance both electronically, and hard copy, and for timely and accurate written documentation to the member and/or provider advising of the resolution of the appeal and/or grievance.
- Responsible for ensuring appeals case files are accurately prepared and submitted to the IRE within 24 hours of the decision to uphold the initial denial for expediated appeals, and not later than 30 calendar days after the receipt of a standard pre-service appeal and 60 days after the receipt of a claim appeal.
- Enter and maintain critical data and records in support of Verda Health Plan business requirements, regulatory obligations timeframes, monitor daily and weekly pending reports and personal worklists, ensuring internal and regulatory timeframes are met.
- Enter and maintain critical data and records in support of business requirements, regulatory timeframes, and NCQA standards, into the appropriate systems.
- Track and trend outcomes and analyze data to provide reporting as required for UM, QA, etc. and to identify provider education opportunities.
- Responsible for monitoring the effectuation of all resolution/outcomes resulting from the appeals, Administrative Law Judge, and Medicare Appeals Council processes.
- Identify areas of potential improvement and provide feedback and recommendations to management on issue resolution, quality improvement, network contracting, policies and procedures, administrative costs, cost saving opportunities, best practices, and performance issues.
- Serve as liaison with medical groups and network physicians to ensure timely resolution of cases; collaborate and partner with internal departments for resolution and education, work with physicians, hospitals and internal staff to gather information needed to resolve complex claim issues.
- Perform other task, project, etc. as needed or directed
- Associate degree, Bachelor’s preferred. In lieu of degree, equivalent education and/or experience may be considered.
- 3 years of related, professional work experience required.
- 2 years’ experience in Medicare Managed Care preferred.
- Experience in a managed care/compliance environment preferred.
- Knowledge of medical terminology, provider reimbursement, medical coding, coordination of benefits and all types of medical claims required.
- Solid understanding of member and provider rights and responsibilities, particularly with appeals and grievance required.
- Familiarity with managed care state and federal regulations is required.
- Prior auditing experience preferred.
- Customer Service experience preferred.
- Knowledgeable in medical terminology and have prior ACD experience.
- Demonstrates good judgment, organization and prioritization skills and time management skills.
- Proven leadership with staff, projects, and management.
- Strategic thinking abilities and analytical skills
- Ability to clearly present written information and findings, concisely communicate concepts and make executive-level presentations.
- Integrity and Trust
- Customer Focus
- Functional/Technical Skills
- Written/Oral Communications
- Critical/Analytical Thinker
Job Type: Full-time
Benefits:- 401(k)
- Dental Insurance
- Health insurance
- Life insurance
- Paid time off.
- Vision insurance
- 8-hour shift
- Monday to Friday/Weekends as needed
- Reliably commute or planning to relocate before starting work (Required)
Regularly sit/walk at a workstation in an office or cubicle setting. Must occasionally lift and/or move up to 25-50 pounds.- Other duties may be assigned in support of departmental goals.
- 2 Days Ago
Lead/Supervisor, Grievance and Appeal - CA
- Verda Healthcare
-
Huntington, CA
FULL_TIME
- Job DescriptionVerda Healthcare, Inc. has a contract with the Center of Medicaid and Medicare Services (CMS) and Texas Department of Insurance for a Medicare Advantage Prescription Drug (MAPD) plan fo...
- 1 Day Ago
Shift supervisor
- Shift Supervisor
-
Palm Springs, CA
FULL_TIME
- Title Shift Supervisor Category Food & Beverage Description Shift Supervisor Job Description Fisherman's Market & Grill Family of Restaurants To achieve your success and growth you will be held respon...
- 23 Days Ago
Tax Preparer/ Tax Resolution Professional
- Tax Resolution Group
-
Huntington, CA
FULL_TIME
- Job DescriptionTax Resolution Group LLC is growing! We are looking for energetic, go-getters to join our expanding team. We are an Accounting Firm located in Huntington Beach, CA. This is an in-office...
- 3 Days Ago
US Accountant
- Human Appeal
-
Los Angeles, CA
FULL_TIME
- Here at Human Appeal, we have an exciting opportunity for a US Accountant to join our team, based at our Los Angeles office. You will join us on a full-time basis for an initial 1-year fixed term cont...
- 6 Days Ago
Case manager- Appeal & Grievance
- Pyramid Consulting, Inc
-
Pleasanton, CA
CONTRACTOR
- Immediate need for a talented Case manager- Appeal & Grievance. This is a 03 Months contract opportunity with long-term potential and is located in Pleasanton, CA (Remote). Please review the job descr...
- 4 Days Ago
Appeal Resolution Supervisor jobs at Popular Companies
Legal Case Manager
- Bighorn Law
-
Las Vegas, NV
- Description Case Manager is to work directly with our Personal Injury Attorneys in a high-volume, fast-paced office envi...
- 6/11/2024 12:00:00 AM
Appeals and Resolution Coordinator
- Westside Regional Center
-
Culver City, CA
- Job Description Job Description Appeals & Resolution Coordinator Requisition #CS-ARC-092723 Closing Date: Open Until Fil...
- 6/11/2024 12:00:00 AM
Litigation Paralegal
- AGG Legal Staffing
-
Los Angeles, CA
- Litigation Paralegal will assist attorneys with various substantive and administrative responsibilities from case incept...
- 6/10/2024 12:00:00 AM
Scheduler
- FLASH Technology Group
-
Fort George G Meade, MD
- Interviewing for a Telephony VTC Scheduler I! TS/SCI with POLYGRAPH clearance necessary! Day Hours, M-F! Tier I, Help De...
- 6/10/2024 12:00:00 AM
Account Resolution Coordinator
- Children's Healthcare of Atlanta
-
Atlanta, GA
- Note: If you are CURRENTLY employed at Children's and/or have an active badge or network access, STOP here. Submit your ...
- 6/9/2024 12:00:00 AM
Claims Examiner - Workers Compensation
- Cynet Systems
-
Long Beach, CA
- Job Description: Pay Range $40hr - $42hr Responsibilities: Manages workers compensation claims determining compensabilit...
- 6/9/2024 12:00:00 AM
Case Resolution Supervisor-Jacksonville
- TEKsystems, Inc.
-
Jacksonville, FL
- Process oversight - Oversee completion of cases submitted to the Center through the tool by their aligned markets. - Ach...
- 6/8/2024 12:00:00 AM
Project Coordinator
- Cynet Systems
-
Boston, MA
- Job Description: Pay Range $29.88hr - $33.88hr Support for the Board of Registration in Nursing. broad range of proven o...
- 6/8/2024 12:00:00 AM
About California
California is a state in the Pacific Region of the United States. With 39.6 million residents, California is the most populous U.S. state and the third-largest by area. The state capital is Sacramento. The Greater Los Angeles Area and the San Francisco Bay Area are the nation's second and fifth most populous urban regions, with 18.7 million and 9.7 million residents respectively. Los Angeles is California's most populous city, and the country's second most populous, after New York City. California also has the nation's most populous county, Los Angeles County, and its largest county by area, S...
Source: Wikipedia (as of 04/11/2019). Read more from Wikipedia
Income Estimation for Appeal Resolution Supervisor jobs
$76,591 to $93,649