Supervises a team of non-clinical staff in the day-to-day workflow processes of the Provider and/or Member Appeal functions. Provides support and guidance daily to the Appeals Provider or Member team in performing their assignments, monitoring the successful delivery and adherence to policies and procedures, as well as supervising daily performance, quality, attendance, and ensures that the department and corporate goals are met. Assists the manager with all appeals project efforts, such as business requirement documents, process flows, and business continuity plans specific to their team's processes.
Reports to: Mgr. Appeals
Department: HS-Appeals & Grievances
Location: Tampa, FL.
Additional Responsibilities:Candidate Education:
- 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. Provides significant input into hiring/termination situations.
- Completes new hire requisitions, conducts interviews and makes hiring decisions for associates in work group.
- Collaborates with department Project Analyst to ensure that all job aids, SATs, workflows, training documents, and processes are current and up to date.
- Receives routine and ad hoc audit results from Appeal Auditors and delivers results to subordinates. Identifies & coordinates additional team member training needs based on associate performance, as well as team trends that may require implementing process improvements.
- Performs primary inventory management and ensures that work is distributed appropriately in order to meet defined production standards as well as turn around times.
- 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.
- Acts as a liaison between Appeals and other business units as it pertains to the Appeals processes, and provides relevant feedback as well as suggestions for improvement that other business units can exercise to ensure success to the Appeals specific compliance and regulatory standards.
- Maintains a routine limited caseload and when necessary provides additional coverage to ensure compliance and t cover work group for PTO or medical leave.
- Acts as a Subject Matter Expert (SME) for area of responsibility.
- Attends company meetings in absence of Manager, Sr. Manager, or Director. Frequently serves on cross-functional WellCare work groups as Appeals (or CSO) representative.
- Makes recommendations and leads process improvements as needs are identified.
- Performs special duties as assigned.
- Required A High School or GED
- Preferred An Associate's Degree in a related field
- Required 4 years of experience in Appeals and/or grievances
- Required 1 year of experience in managed care
- Preferred Other Previous experience working in a supervisory, lead, or senior capacity that involved mentoring or training of others.
- Intermediate Ability to effectively present information and respond to questions from peers and management
- Intermediate Ability to effectively present information and respond to questions from families, members, and providers
- Intermediate Demonstrated interpersonal/verbal communication skills
- Intermediate Demonstrated written communication skills
- Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
- Required Intermediate Microsoft Excel Working knowledge of Microsoft Office Products including Outlook, Word and Excel
- Required Intermediate Microsoft Word Knowledge of or ability to learn and use personal computers and industry software including Peradigm, Sidewinder, and EMMA
- Required Intermediate Microsoft Outlook
- Required Intermediate Healthcare Management Systems (Generic)