Supervisor, Clinical Appeals

Location: 8715 Henderson Road, Tampa, FL 33634

Reports to: Director, Clinical Appeals

Department: Clinical Appeals

Job Type: Exempt - Salary

Supervises a team of Appeals Review Nurses in the day-to-day workflow processes of the Provider and/or Member Appeal functions.

Essential Functions:

  • Utilizes clinical knowledge to apply information to WellCare's designated criteria in order to make authorization decisions and assist the Medical Director with appeal determinations.
  • Reviews information provided by Appeal Review Nurses concerning eligibility, provider status, benefit coverage, coordination of benefits and subrogation necessary to reach prospective, concurrent and retrospective decisions in the appeals process.
  • Troubleshoots more complex cases elevated by nurses. Reviews and interprets a variety of instructions and medical notes furnished in written and oral form to determine appropriate action within the appeal process.
  • Monitors associate performance for timely and accurate processing of appeals, attendance, schedules, and other job related behavior. Ensures the collection, interpretation and safekeeping of all materials concerning each appeal.
  • Reviews appeal management and error reports to ensure associate productivity, accuracy and timeliness. Gives subordinates regular feedback on performance and conducts counseling/corrective action procedures, up to and including separation, with manager and HR oversight when needed.
  • Writes midyear and annual performance evaluations and reviews with associates.
  • Completes new hire requisitions, conducts interviews and makes hiring decisions for associates in work group. Ensures comprehensive training for each new hire, including intensive period of supervision for first 90-120 days.
  • Receives routine and ad hoc audit results from Appeal Auditors and routinely delivers results to subordinates. Identifies & coordinates additional team member training needs based on associate performance.
  • Answers internal and external customer questions, assists peers and Manager, Sr. Manager or Director with tasks. Serves as first line contact for the company’s problem resolution procedure for associates in his/her work group. Serves as liaison for escalated appeal issues identified by the Provider Relations team..
  • Plays active role in creating, applying and utilizing accepted policies and procedures to review process and utilizes the parameters.
  • Monitors decisions made by Appeals Review Nurses to ensure correct application of criteria utilized in making clinical decisions not involving a Medical Director and ensures appropriate use of admission authorizations.
  • Attends company meetings in absence of Manager, Sr. Manager or Director. Frequently serves on cross-functional WellCare workgroups as Appeals (or Health Services) representative.
  • Maintains a routine limited caseload and when necessary provides additional coverage to maintain compliance and to cover work group for PTO or medical leave.
  • Makes recommendations and leads process improvement as needs are identified.
  • Reviews appeal outcome reports that identify numbers, trends or patterns in the appeals process and reports findings to manager, director, other departments, and any committees as necessary.
  • Performs other duties as assigned.
Additional Responsibilities:
    Candidate Education:
    • Required A High School or GED
    • Preferred An Associate's Degree in a related field nursing
    Candidate Experience:
    • Required 4 years of experience in A clinical or managed care setting with exposure to pre-authorization, utilization review, concurrent review, and/or discharge planning.
    • Required 1 year experience in leading/supervising others In a clinical or managed care setting (preferred) where you functioned in a team lead or senior capacity, providing mentoring, training, support, and guidance and functioned as a subject matter expert (SME)
    Candidate Skills:
    • Intermediate Demonstrated negotiation skills Demonstrated negotiation skills
    • Intermediate Ability to lead/manage others
    • Intermediate Demonstrated problem solving skills
    • Intermediate Demonstrated interpersonal/verbal communication skills
    • Intermediate Knowledge of community, state and federal laws and resources Knowledge of community, state and federal laws and resources
    • Intermediate Ability to effectively present information and respond to questions from families, members, and providers Ability to effectively present information and respond to questions from families, members, and providers
    • Intermediate Ability to lead/manage others in a matrixed environment
    • Intermediate Other Knowledge of Utilization Management principles and criteria sets such as InterQual, Medicare guidelines,etc
    • Intermediate Other Strong clinical knowledge on broad range of medical practice specialties
    Licenses and Certifications:
    A license in one of the following is required:
    • Required Licensed Practical Nurse (LPN)
    • Preferred Licensed Registered Nurse (RN)
    Technical Skills:
    • Preferred Intermediate Microsoft PowerPoint Proficient in Microsoft Outlook applications, including Word, Excel, PowerPoint and Outlook
    • Required Intermediate Microsoft Excel
    • Required Intermediate Microsoft Word Ability to use proprietary health care management system
    • Required Intermediate Microsoft Outlook
    • Required Intermediate Healthcare Management Systems (Generic)

      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.