Appeals Manager Job Description

Appeals Manager Job Description

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Appeals manager provides customer support on employee benefits questions related to health insurance, disability insurance, and other benefit programs.

Appeals Manager Duties & Responsibilities

To write an effective appeals manager job description, begin by listing detailed duties, responsibilities and expectations. We have included appeals manager job description templates that you can modify and use.

Sample responsibilities for this position include:

Analyze findings and recommends performance improvement initiatives and/or corrective actions
Assist management with ensuring compliance with regulatory requirements for all products
Maintains and coordinates staff activities to achieve departmental and corporate goals to improve service to customers/providers and assures regulatory compliance
Analyzes and develops strategies by achieving performance thresholds within budgetary guidelines
Addresses both internal/external customer/provider needs and concerns related to team activities
Ensures programs support overall QI program and meet regulatory compliance/accreditation and the company standards
Monitors, trends and analyzes grievance and appeals data for submission to appropriate parties
Serves as process expert and mentor to unit and other departments for complex issues and interpretation of regulatory standards
May perform internal audits of grievance and appeals process
Ensures appeals and grievances are resolved within regulatory timeframes

Appeals Manager Qualifications

Qualifications for a job description may include education, certification, and experience.

Licensing or Certifications for Appeals Manager

List any licenses or certifications required by the position: FEMA, CPC, MCG, CCS, AAHAM, SAS, SQL, RHIA, TQM

Education for Appeals Manager

Typically a job would require a certain level of education.

Employers hiring for the appeals manager job most commonly would prefer for their future employee to have a relevant degree such as Bachelor's and Collage Degree in Education, Healthcare, Performance, Nursing, Law, Business, Management, Health, Associates, Graduate

Skills for Appeals Manager

Desired skills for appeals manager include:

Benefits
Claims processing
ERISA
Enrollment and billing
Group disability
Health insurance plans
Medicare Advantage Experience
State laws
Terminology
ACA

Desired experience for appeals manager includes:

Monitor inventory, productivity, timeliness, quality and ensure CMS regulatory requirements are met
Attend multiple meetings and present to multiple levels of management
Understand and apply all CMS, State and Client requirements related to grievances and appeals company policies related to benefit administration for all lines of business
Oversight and leadership of a team of clinical pharmacists, technicians and contractors that support the clinical pharmacy appeals unit
Maintains knowledge and proficiency in state/federal regulations and the appeals review process
Manages the day-to-day appeals operations and performance of the team (up to 20 direct reports)

Appeals Manager Examples

1

Appeals Manager Job Description

Job Description Example
Our company is growing rapidly and is searching for experienced candidates for the position of appeals manager. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for appeals manager
  • Sets team direction, resolves issues and provides guidance to team ensuring policy and procedures are appropriately followed
  • Collaborates cross-functionally with key business stakeholders to meet service level agreements, resolve issues, and partner on improvement opportunities
  • Identifies and implements quality and process improvements to maximize efficiencies
  • Monitors, trends and analyzes grievance denials, and appeals data for submission to appropriate parties
  • Serves as clinical resource expert and mentor to unit and other departments for complex issues and interpretation of regulatory standards
  • May perform internal audits of grievance, denials, and appeals process
  • Performs internal audits of grievance, denials, and appeals process
  • Reviews prospective or retrospective medical records of denied services for medical necessity
  • Serves as subject matter expert for team and works on projects impacting development, interpretation, and implementation of medical policy or other managed care initiatives that may cross functional lines or sta
  • Manage daily activities and inventory related to SSC Appeals function, ensuring processes are performed accurately, efficiently and effectively within all established operational and SOX guidelines
Qualifications for appeals manager
  • Medical management process
  • Company's internal business processes
  • Microsoft Office Products (Word, Excel, and Outlook)
  • Minimum of five years’ recent acute care experience with medical-surgical/critical care preferred
  • Utilization and/or Case Management experience recommended
  • Comprehensive knowledge and application of InterQual® preferred
2

Appeals Manager Job Description

Job Description Example
Our company is growing rapidly and is looking for an appeals manager. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for appeals manager
  • Coordinate with all necessary departments related to contract issues
  • Perform QA for all processes within Appeals
  • Work as a liaison between the Appeals staff and other SSC staff
  • Resolve issues escalated by Appeals staff
  • Closely monitors and leads ongoing review of Appeals & Grievances metrics, performance, improvements, and issues with business partners and A&G teams
  • Conducts root cause analysis on appeals that contribute to decrease in performance and failure to meet commitments to understands reasons for not meeting state requirements, developing action plans to address the issues / gaps with the cross functional teams
  • Provides support and coordinates with UHC Benefit Operations for any A&G needs in audits or regulatory inquiries
  • Supervise a team of Student Appeals Officers and one FTE Office Specialist
  • Provide continuing training to Student Appeals Officers to ensure department and university goals are met
  • Prepare work schedules student workers
Qualifications for appeals manager
  • Certified Case Manager (CCM) or Certified Professional in Utilization Review/Utilization Management/Healthcare Management (CPUR , CPUM, or CPHM) preferred
  • Health insurance experience is highly preferred
  • Lead point of contact for PTS employees for In Contact questions
  • Send Dean’s Referrals when necessary
  • Provide in person customer service to customers who are disputing citations
  • Handle all Salesforce cases pertaining to appeals
3

Appeals Manager Job Description

Job Description Example
Our company is growing rapidly and is hiring for an appeals manager. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for appeals manager
  • Process appeal requests as necessary
  • Attend a weekly customer service meeting to communicate information relating to appeals
  • Perform account maintenance in Flex
  • Complete MVD searches to help identify customers and assign citations
  • Educate customers on reasons they are receiving citations and how to remedy the situation
  • Collaborate with Dispatch to resolve customer issues
  • Send Certified Letters when needed
  • Process all refunds pertaining to Appeals
  • Process void requests by other PTS departments
  • Coordinate recruitment to include processing requests for hires, screening applicants, participating in the interviewing process
Qualifications for appeals manager
  • Develop and schedule program work plan in accordance with specifications
  • Participate in and oversees Tabling Events such as New Employee Orientation, New Student Orientation and other tabling events providing information, interacting with patrons, ensuring sufficient staffing needs are met, ordering giveaways, and setting up venue
  • Oversee projects in the Customer Service area
  • Prepare periodic reports on program activities, progress, status or other special reports for management
  • Develop, compile, and write communications related to Appeals
  • Interact and maintain liaison with students, faculty and staff
4

Appeals Manager Job Description

Job Description Example
Our company is looking to fill the role of appeals manager. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for appeals manager
  • Conducts Case Management compliance trend analyses from system reports, identifies gaps, and develops program components to mitigate identified gaps
  • Conducts appeal and denial reviews and trend analysis from various sources, such as audit reports, RAC/MAC trackers, and other appeal and denial information to assist in revising the appeal and denial processes to ensure optimum patient outcomes with appropriate utilization of services
  • Provides ongoing evaluation and assessment of Facility practices and industry changes to ensure the enterprise remains current in processes related to appeals and denials
  • Partners with Division Managed Care Department to engage with different payors to provide feedback regarding trends and issues
  • Engages with individual facilities to identify unique concerns and assists with development of action plans
  • Conducts ongoing research to remain current in evidence-based best practices
  • Maintains and articulates current knowledge and understanding of all corporate policies and procedures related to job function
  • Oversees the unit and staff members reviewing disability and workers compensation claims
  • Makes recommendations on training needs
  • Ensures effective process management
Qualifications for appeals manager
  • Demonstrated knowledge of and practical application of Conflict Resolution methods
  • Experience in customer service (1 year)
  • Experience in marketing and outreach 1 year)
  • Four years of supervisory experience or prior experience supervising a student workforce in a higher education setting
  • Experience in organizing works activities and people
  • Evidence of effective verbal and written communication skills (i.e., accurate grammar and spelling)
5

Appeals Manager Job Description

Job Description Example
Our innovative and growing company is hiring for an appeals manager. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for appeals manager
  • Generates reports of denial activity on a monthly basis with analysis of data and significant trends to the leadership team Perform retrospective record reviews providing clinical updates to insurer in a timely manner
  • Serve as a resource to Finance, Patient Access, Coding, Patient Accounts and various clinical departments in clarifying hospital status for specific accounts
  • Perform prebill audits on all inptatient stays that do not meet the 2 midnight rule and assure the proper level of care
  • Develop and track indicators and report trends to Director and CFO
  • Strategic design and implementation of Quality Improvement process and infrastructure, policies, procedures, workflows
  • Directs all quality training activities
  • Direct the daily Medicare appeals and grievance activities to ensure best in class resolution and service ensure compliance with policies, procedures and regulation
  • Responsible for day to day activities, Management and oversight of Technical Denials Appeal department - this includes ensuring communication to team on overall communication on projects, activities, goals and metrics related to department and within the larger AR
  • Responsible for Inventory management - ensuring adherence to monthly goals and documentation and action plans to goals when unable to meet
  • Manage levels of performance and assist with employees’ professional growth by planning and building an effective organization
Qualifications for appeals manager
  • Experience in T2 Flex (1 year)
  • Experience in Sale Force (1 year)
  • Maintains call tracking system of correspondence and outcomes for Providers appeals/grievances
  • Experience reviewing all types of medical claims
  • 3-5 years acute care case management experience required
  • Denials and Appeals Management experience required

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