Director, Appeals

Plans, provides resources and directs activities within the Appeals department. Serves as departmental representative and works collaboratively to develop and monitor appropriate indicators of business success. Leads Appeals Management team by focusing on day to day business of appeals completion and throughput. Oversees process and inventory management, case resolution, claims effectuation, turn-around times, quality, and staffing metrics.

Reports to: Senior Director Appeals

Department: Population Health Services

Position Located: Tampa, FL

Essential Functions:

  • Manages and develops direct reports who include management personnel and/or exempt individual contributors. With the approval of the Sr. Director, establishes budget and monitors for adherence.
  • Conducts employee evaluations and completes any disciplinary actions that may be required.
  • Leads Appeals leadership team by focusing on day to day business of appeals completion and throughput. Oversees process and inventory management, claims effectuation, turn-around–times and staffing metrics.
  • Assists the leadership team with escalated appeal issues coming from internal and external customers.
  • Drives departmental initiatives to eliminate barriers impacting Appeal resolution. Works collaboratively with other departments to ensure consistency in work flow processes and that departmental goals all support the corporate goals.
  • Reports Appeals statistics and trends at the Market Medical Advisory Committees, Quality Improvement Councils and the Joint Customer Service Quality Initiative Work groups. Ensures that all reports to outside agencies are properly and accurately completed in a timely manner.
  • Participates in audits and/or site visits by federal, state, and/or accreditation bodies by collecting, reviewing and quality checking deliverables. Serves as key contact for the Medical Directors supporting the Appeals Process
  • Acts as a liaison for all Legal, Compliance, and Regulatory Departments for departmental issues such as appeals compliance, external hearings and legal proceedings.
  • Leads activities to identify areas of compliance risks for provider relations and operations against state and federal provider network requirements.
  • Coordinates or leads process improvement initiatives, seeking root cause and developing appropriate corrective action.
  • Responsible for appeals department training including developing and maintaining training materials and training program and responsible to provide mentorship and overall guidance to the department trainer.
  • Performs special projects as assigned.
Additional Responsibilities:
    Candidate Education:
    • Required A Bachelor's Degree in a related field or equivalent work experience
    Candidate Experience:
    • Required 7 years of experience in a leadership role in one of the following areas: Operations, Finance, Regulatory, IT, etc.
    Candidate Skills:
    • Intermediate Ability to communicate and make recommendations to upper management
    • Intermediate Ability to drive multiple projects
    • Intermediate Ability to effectively present information and respond to questions from peers and management
    • Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
    • Intermediate Ability to implement process improvements
    • Intermediate Ability to work in a fast paced environment with changing priorities
    • Advanced Demonstrated time management and priority setting skills
    • Advanced Ability to work within tight timeframes and meet strict deadlines
    Licenses and Certifications:
    A license in one of the following is required:
      Technical Skills:
      • Required Intermediate Financial Management Systems (Generic)
      • Required Intermediate Healthcare Management Systems (Generic)
      • Required Intermediate Microsoft Excel
      • Required Intermediate Microsoft PowerPoint
      • Required Intermediate Microsoft Word
      • Required Intermediate Microsoft Outlook
      • Required Beginner Microsoft Visio

        About us
        Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses exclusively on providing government-sponsored managed care services through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans to families, children, seniors and individuals with complex medical needs. WellCare is a Fortune 500 company, and in 2018, was recognized as a Fortune "World's Most Admired Company", ranking in the top five among the health insurance and managed care industry-a testament to the hard work and dedication of the company's nearly 9,000 associates who each day live WellCare's values and deliver on its mission to help its members live better, healthier lives. The company serves approximately 4.4 million members nationwide as of Dec. 31, 2017. For more information about WellCare, please visit the company's website at EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.