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Corporate Functions & Operations WellCare - Operations Management Careers

Clinical Appeals - Manager Job

Full Job Title: Mgr, Clinical Appeals

Job Number: 1704830

Location: Tampa, FL

Date Posted: 11-1-2017

Manages the activities of supervisory associates and their subordinate work group(s) and/or exempt individual contributors for assigned area of Appeals responsibility. Plans, directs, and coordinates appeals on behalf of the Plan.
Reports to: Sr.Dir. Appeals/Retro Review
Department: HS-Appeals & Grievances
Location: Tampa, FL.
Essential Functions:
  • Manages and develops direct reports who include supervisory and/or clinical professional personnel.
  • Directs work assignments, measures results and initiates personnel actions as required.
  • Interprets reports to identify numbers, trends or patterns in the appeals process and report to any committees as necessary.
  • Manages inventory by ensuring all productivity and timeliness standards are met.
  • Ensures proper record of all appeals as required by law, regulation or good business management principal.
  • Ensure that policies and procedures comply with statutes or regulations that apply and that they are strictly adhered to.
  • Ensures that all reports to outside agencies are properly and accurately completed in a timely manner.
  • Works with Human Resources on staffing and training requirements to complete the tasks assigned.
  • Collaborates with other departments and market representatives as needed to clarify and resolve appeal related issues.
  • Ensures decisions from Federal and State agencies, and/or their contractors are adjudicated appropriately and timely, in accordance to regulations.
  • Conduct employee evaluations and complete any disciplinary actions that may be required.
  • Performs special projects as assigned.
Education: Licensed Practical Nurse. BSN preferred.
Experience: 5 years experience in a utilization management setting with experience in ER/critical care, discharge planning and bedside care. 3 years in managed care. 1 years in a management/supervisory position
Licenses/Certifications:
  • Licensed Practical Nurse
  • Registered Nurse (Preferred)
Special Skills (e.g. 2nd language): Strong clinical knowledge on broad range of medical practice specialties. Knowledge of Utilization Management principles and criteria sets such as InterQual, Medicare guidelines,etc. Ability to manage a team in a metrics driven environment. Demonstrated negotiation skills. Demonstrated ability in problem solving and communication. Previous experience working with treatment teams to meet the healthcare needs of participants. Knowledge of community, state and federal laws and resources. Ability to effectively present information and respond to questions from families, members, and providers.
Technical Skills/Requirements: Proficient in Microsoft Outlook applications, including Word, Excel, PowerPoint and Outlook. Ability to use proprietary health care management system.

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Last Updated On: 12/9/2015