Location: Tampa Corporate Office (8715 Henderson Road, Tampa, FL 33634)
Reports to: Senior Manager, Clinical Appeals
Department: Clinical Appeals
Level: L17 (Exempt - Salary)
Supervises a team of non-clinical staff to ensure timely and accurate throughput of ER Prudent LayPerson (PLP) intake volumes. Supports the PLP review area through working with appropriate internal and external staff to assess incoming volumes and processes. Supports the management processes through continued process improvement, data validation and progress towards department goals.
Additional Responsibilities: Candidate Education:
- Coordinates non-clinical team for the assumption of incoming volumes, and communicates daily changes to volume assignments.
- Reduces turnaround times for production based on staffing adjustments to meet volume demands.
- Collaborates with the chart scanning vendor and operations mailroom to verify incoming volumes and to manage production output so that there is a continual stream of work within the area.
- Assesses the volume needs of the ER PLP area and communicates volumes to key associates.
- Generates, distributes and interprets production level reports and implements actions based on metric level reporting.
- Develops, communicates and implements ER PLP process improvements to both intake and closing procedures to increase efficiency and accuracy.
- Provides incident resolution to ER PLP issues where claims payment, member identification or process points require correction.
- Works closely with internal partners, e.g.. Claims, Market Network Development to resolve provider issues.
- Conducts associate counseling and discipline process as needed. Completes associates' performance evaluations.
- Works directly with Medical Directors to review case dispositions for ER PLP reconsiderations.
- Develops onboarding and training programs for both new hires and current staff.
- Builds effective bridges of communication and fosters teamwork among the associate team.
- Performs special duties as assigned, including special projects.
- Required A High School or GED
- Preferred An Associate's Degree in a related field
- Required 4 years of experience in work directly related to Retrospective Review
- Required 1 year of experience in managed care
- Preferred 1 year experience in leading/supervising others
Licenses and Certifications:
- Intermediate Ability to effectively present information and respond to questions from families, members, and providers
- 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 lead/manage others
- Intermediate Demonstrated interpersonal/verbal communication skills
- Intermediate Demonstrated organizational skills
- Intermediate Demonstrated written communication skills
- Intermediate Ability to work within tight timeframes and meet strict deadlines
- Intermediate Knowledge of healthcare delivery
A license in one of the following is required:
- Required Intermediate Healthcare Management Systems (Generic)
- Required Intermediate Microsoft Excel
- Required Intermediate Microsoft Word
- Required Intermediate Microsoft Outlook