Appeals Manager Resume Samples

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HA
H Abernathy
Henri
Abernathy
749 Myles Stravenue
Dallas
TX
+1 (555) 971 7383
749 Myles Stravenue
Dallas
TX
Phone
p +1 (555) 971 7383
Experience Experience
Philadelphia, PA
Appeals Manager
Philadelphia, PA
Bradtke, Schiller and Gislason
Philadelphia, PA
Appeals Manager
  • Oversee daily operations of multiple levels of staff and multiple functions across one or more business units
  • Provide expertise or general claims support to teams in reviewing, researching, investigating, negotiating, processing and adjusting claims
  • Conduct data entry and re-work; analyzes and identifies trends and provides reports as necessary
  • Lead project management and implementation initiatives
  • Impact of work is most often at the local level
  • Identifies continuous quality improvement measures through appeal result analysis while partnering with the operations team ensuring best practices are met
  • Monitors changes to the ERISA legislation; incorporates workflow changes into the process as defined in legislative changes
Philadelphia, PA
Manager, Medicare Advantage Appeals
Philadelphia, PA
Boyer-Jast
Philadelphia, PA
Manager, Medicare Advantage Appeals
  • Conducts all auditing activities for assigned area; trends appeals and facilitate meetings to review data for process/product improvements
  • Collaboration with Highmark’s Provider Network
  • Collaboration within interdepartmental work groups i.e. Care Management Systems, Provider Services, Medicare C&D Compliance, Pharmacy, Quality Improvement, Product staff, Provider Reimbursement and Contracting
  • Actively involved in MM&P and MA Appeals operational performance in relation to monthly STARS results. Critical responsibility to achieve maximum STARS ratings which has financial impact to Highmark, Inc is to conduct tracking, trending and process improvement for operational processes that impact STARS performance
  • Identify, develop, and implement division/department projects which are focused on quality, utilization, process and/or outcome improvements. Identify industry benchmarks through scientific research and literature searches on order to assure Medical Management & Policy exceeds industry standards
  • Collaboration with interdepartmental work groups i.e. Compliance and Quality, Operations and Physician Advisors
  • Other duties as assigned or requested
present
Philadelphia, PA
Manager of Denials & Appeals
Philadelphia, PA
Pagac, Ondricka and Heidenreich
present
Philadelphia, PA
Manager of Denials & Appeals
present
  • Collaborates with Finance, revenue cycle personnel, physicians, contracting team, case managers, and payers to appeal denials and mitigate trends
  • Keeps up-to-date on issues surrounding commercial and government payer regulations and processes around audits and denials, and implementing policies and procedures to assure compliant and accurate billing practices
  • Develop and track indicators and report trends to Director and CFO. Provide feedback to department regarding changes in third party expectations as well as any trends in denial activity
  • Responsible for analyzing and interpreting trends associated with denials and appeals to effectively manage reimbursement and build strategies for mitigating future denials
  • Perform prebill audits on all inptatient stays that do not meet the 2 midnight rule and assure the proper level of care. Notify finance of outcome of audit
  • Perform retrospective record reviews providing clinical updates to insurer in a timely manner. Utilize written and verbal exchange of clinical information for the purpose of providing clear, unambiguous clinical review to payer for purposes of payment determination
  • Serve as a resource to Finance, Patient Access, Coding, Patient Accounts and various clinical departments in clarifying hospital status for specific accounts. Stays concurrent on and provides education on regulatory changes as it relates to level of care determination, discharge planning, and appeals and denials
Education Education
Bachelor’s Degree in Nursing
Bachelor’s Degree in Nursing
Quinnipiac University
Bachelor’s Degree in Nursing
Skills Skills
  • Excellent knowledge of disability claims management practices
  • Strong organizational skills and attention to detail
  • Ability to build professional relationships
  • Policies & Procedures - demonstrates knowledge and understanding of organizational policies, procedures and systems
  • Ability to work in a team environment
  • Able to work well individually, in teams and work virtually
  • Communication - communicates clearly and concisely, verbally and in writing. This includes utilizing proper punctuation, correct spelling and the ability to transcribe accurately. The ability to communicate with staff, Parallon Management, Division and Group Executives
  • Excellent negotiation skills
  • Interpersonal Skills - able to work effectively with other employees, patients and external parties
  • Leadership - guides individuals and groups toward desired outcomes, setting high performance standards and delivering leading quality services
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12 Appeals Manager resume templates

1

Appeals Manager Resume Examples & Samples

  • 10+ years in Housing Programs with emphasis on Disaster Recovery
  • Strong analytical, quantitative, problem-solving and decision making capabilities
  • Ability to prioritize and multi-task in a fast-paced environment
  • Able to work well individually, in teams and work virtually
2

PDP Appeals Manager Resume Examples & Samples

  • Progressive operational experience in a formal or informal leadership role
  • Leadership experience over a large metric-intensive operational unit
  • Proficient in Microsoft Applications
  • Certification with SixSigma and/or the Project Management Institute is very helpful
  • Grievance and appeals experience
3

Case Manager Appeals Resume Examples & Samples

  • Education: Bachelors, Associate Degree or diploma in Nursing
  • Experience: 3 years clinical experience. Experience in Case Management, Quality Management and/or Appeals Management preferred
  • Licensure: Current RN license, State of Michigan
4

Grievances & Appeals Manager Resume Examples & Samples

  • Fully bilingual English/Spanish
  • Strong computer skills including MS Office desktop applications (Word, Excel, PowerPoint, Visio, Project)
  • Demonstrated competency in both oral and written communication skills
  • Proven knowledge in Medicare regulations
5

Senior Manager Medicare Appeals & Grievances Resume Examples & Samples

  • Oversight and manage approximately 100 appeals staff in the US, including global partner performance
  • Monitor inventory, productivity, timeliness, quality and ensure CMS regulatory requirements are met. (Responsible for 10,000+ pieces of correspondence per day)
  • Analyze and troubleshoot variances in inventory and proactively take action plans to address variances
  • Manage the organization utilizing the principles and processes of the United Operating Model
  • Manages appeals and grievances (Medicare)
  • Attend multiple meetings and present to multiple levels of management. Be able to articulate solutions to issues for management
  • 2 + years of operational experience with inventory or call volume management experience
  • 2+ years of management experience with increasing responsibility
  • Proficient Microsoft Word, Excel, PowerPoint and keyboarding skills
  • Prior experience with Medicare claims or Appeals and Grievances or CTMs
  • Demonstrated ability to provide constructive feedback and developmental coaching in a clear and respectful manner
  • Experience in identifying opportunities for customer improvement and process efficiencies
  • Effective at establishing strategic plans and objectives to ensure operational discipline, operational effectiveness and operational execution
  • Experience managing employees from multiple office locations as well as work from home employees
  • 5+ years of Medicare, Medicaid or Commercial Health Insurance experience
  • 5+ years of operational experience with inventory or call volume management experience
  • Experience working with vendors and employees in India
  • 2+ years of root cause analysis and research (i.e., Six Sigma experience)
  • Demonstrated experience in taking initiative in making decisions and taking action to delivery on required outcomes
  • Effective verbal / written communication skills; (i.e. Effective verbal / written communication skills; as you will be responsible for speaking with business partners and internal leadership regarding federal level compliance, requirements, and improvement plans
6

Appeals & Grievance Manager Resume Examples & Samples

  • Understand and apply all CMS, State and Client requirements related to grievances and appeals as well as company policies related to benefit administration for all lines of business
  • Manage team of staff working appeals & grievances and develop/maintain necessary training programs on relevant CMS, State, and Health Plan requirements
  • Create & Maintain A&G policies, processes and procedures, and workflows. Ensure data for CMS, State and other regulatory reports and data validation audits is accurate and complete
  • Supervise the creation, maintenance, and communication of dashboards of appeals and grievances received, status and resolution
  • Develop the necessary reporting infrastructure to identify and trend A&G incidents and partner with cross-functional business partners to resolve upstream root causes
  • Participate in relevant cross-functional committees, including those charged with making determinations regarding exceptions to standard policies, Compliance oversight, and Stars
  • Maintain confidentiality of member, physician and employee information
  • Foster strong professional working relationships with others in the company, delegates and external agencies to aid in the implementation of cross-functional cooperation and improvement of interdepartmental processes
  • Represent Prominence Health in a courteous manner in attitude and appearance, behaving ethically and using a professional demeanor in oral and written communications with internal and external customers
  • Adhere to all company compliance standards
  • 8+ years of progressive industry experience in appeals & grievance, customer service, health plans, managed care, provider relations, and/or utilization management
  • Prior experience working in Medicare Part C and D appeals strongly preferred
  • Established track record of managing staff working under tight deadlines
  • Must possess strong team management, problem-solving skills, project management and negotiation skills and have the ability to multi-task in an effective and organized manner
  • Ability to establish and maintain good working relationships with staff, external customers and government agencies, as necessary
  • Solid understanding of claims payment and care management systems, general health plan operations, and benefit plans
  • Understanding of government billing regulations, including; State DOI rules, Medicare Managed Care, and Medical Terminology
7

Manager, Grievance / Appeals / Denials Resume Examples & Samples

  • SharePoint
  • Facets
  • Macess
  • Pega Appeals
  • RN, LPC, or LCSW license
8

Appeals Manager Resume Examples & Samples

  • Customer Orientation- establishes and maintains long-term customer relationships, building trust and respect by consistently meeting and exceeding expectations
  • Interpersonal Skills - able to work effectively with other employees, patients and external parties
  • PC Skills- demonstrates proficiency in Microsoft Office applications and others as required
  • Tactical Execution - oversees the development, deployment and direction of complex programs and processes
  • Project Management - assesses work activities and allocates resources appropriately
  • Basic Skills- demonstrates ability to organize, perform and track multiple tasks accurately in short timeframes, have ability to work quickly and accurately in a fast-paced environment while managing multiple demands, ability to work both independently and collaboratively as a team player, adaptability, analytical and problem solving ability and attention to detail and able to perform basic mathematical calculations, balance and reconcile figures, punctuate properly, spell correctly and transcribe accurately
  • Minimum three years’ experience in related area with two of these years being healthcare management experience OR completion of the Parallon Manager Trainee Program
9

Manager Denials & Appeals Resume Examples & Samples

  • Current, unencumbered license to practice as a Registered Nurse
  • Five (5+) years’ home health experience
  • Three (3+) years’ management experience
  • One (1+) year denials and appeals experience
  • Knowledge of updated coding compliance guidelines, coding clinic references and CMS regulations
  • Certification in OASIS and HCS-D coding within first nine (9) months in position
10

Manager, Appeals & Grievances Resume Examples & Samples

  • Manages staff responsible for the submission/resolution of Provider inquiries, appeals and grievances for the Plan. Ensures resolutions are compliant
  • Proactively assesses and audits business processes to determine those most effective and efficient at resolving Provider problems
  • Serves as primary interface with Corporate Claims and Configuration counterparts and ensures standard processes are implemented
  • Oversees preparation of narratives, graphs, flowcharts, etc. to be used for committee presentations, audits and internal/external reports; oversees necessary correspondence in accordance with regulatory requirements
  • Maintains call tracking system of correspondence and outcomes for Providers appeals/grievances; oversees monitoring of each member submission/resolution to ensure all internal and regulatory timelines are met
  • Experience reviewing all types of medical claims (e.g. HCFA 1500, Outpatient/Inpatient UB92, Universal Claims, Stop Loss, Surgery, Anesthesia, high dollar complicated claims, COB and DRG/RCC pricing)
  • 6+ years experience in healthcare claims review and/or member dispute resolution; supervisory or management experience
11

Appeals Manager Resume Examples & Samples

  • Minimum 3 years management experience preferably in a multi-site/multi-state environment
  • Must have a Financial/Accounting, Clinical Appeals, and/or Hospital Revenue Cycle background
  • Ability to articulate problems/claim issues to insurance provider reps clearly and be able to collaborate with them, and HCA contracting, to resolve
  • Background interacting with Hospital Case Mgmt and/or involvement in Utilization Mgmt process a plus (understanding of prior authorization process)
  • Ability to Identify Trends
  • Ability to build and maintain internal and external relationships
  • Solid written and oral skills
  • Proven track record of inventory management and account resolution
  • Proven track record managing staff productivity and quality
  • Proven track record of successful process improvement in account resolution
  • * ONLY CANDIDATES WITH SALARY REQUIREMENTS LISTED WILL BE CONSIDERED**
12

NV MCD Manager, Grievance & Appeals Resume Examples & Samples

  • Direct experience processing Medicaid or Medicare Grievances and Appeals
  • 5 years’ experience as a Grievance and Appeal Analyst, or 3 years’ experience as a; Sr. Grievance and Appeal Analyst, Grievance and Appeal Consultant, Grievance or Appeal Supervisor/Manager
  • Experience with operations or project management a plus
  • Knowledge of ICD-9 and CPT codes desired
  • Data Management experience required
  • Experience implementing regulatory requirements and understanding of state and federal laws
  • Previous mgmt experience including the hiring, development and coaching of staff
  • Exceptional communication skills written and verbal; able to present in public forums
  • Experience and demonstrated ability to read and understand complex documents
13

Manager Appeals Resume Examples & Samples

  • Knowledge of CMS regulatory guidelines (i.e. Chapters 13 and 18). Works with Compliance/ Regulatory Affairs and Legal teams that support the Government business units for interpretation of guidelines to resolve member appeal issues
  • Strong understanding of benefit operations functional areas that have an upstream/downstream impact
  • Develop working relationships with internal business partners for problem resolution purposes
  • Works closely with Legal, Compliance and Regulatory Affairs
  • Identify process gaps and lead process improvement activities
  • Proactively manage inventory, overtime, and throughput
  • Four year College Degree with strong preference for advanced degree
  • Strong communication and presentation skill set with the ability to present data to all levels of the Executive team across Government Claims and Benefit Operations
  • Experience in appeals and grievances capacity
  • Experience in dealing with Medicare products and services
  • Strong problem resolution skill sets with the ability to manage conflict in a professional and productive manner with stakeholders and team members
  • Advanced written communication skills including grammatical composition and spelling
  • Available to work flexible work schedules and work extended hours including weekends on a consistent basis in order to meet CMS deadlines
  • Strong analytical and root cause skills with previous experience in driving process improvements
  • Ability to ask appropriate questions and actively listen to identify underlying questions and issues (root cause analysis)
14

Manager of Appeals & Grievances Resume Examples & Samples

  • Manages staff responsible for the submission/resolution of member inquiries, appeals and grievances for the Plan. Ensures resolutions are compliant
  • Proactively assesses and audits business processes to determine those most effective and efficient at resolving member problems
  • Maintains call tracking system of correspondence and outcomes for member appeals/grievances; oversees monitoring of each member submission/resolution to ensure all internal and regulatory timelines are met
  • Min. 4 years experience in healthcare claims review and/or member dispute resolution
  • Experience reviewing all types of medical claims (e.g. HCFA 1500, Outpatient / Inpatient UB92, Universal Claims, Stop Loss, Surgery, Anesthesia, high dollar complicated claims, COB and DRG / RCC pricing)
15

Manager, Grievance / Appeals Resume Examples & Samples

  • Requires 3-5 years leadership experience in grievance & appeals, claims or customer services in the healthcare industry; or any combination of education and experience, which would provide an equivalent background
  • Clinical license preferred
  • Facets, Maccess, Pega experience preferred
  • Medicaid knowledge preferred
  • LTSS service coordination experience preferred
16

Manager, Medicare Advantage Appeals Resume Examples & Samples

  • Maintain consistent and open lines of communication with internal and external customers; including facilitating informational and education meetings. Seek always to communicate changes in processes and programs order to enhance a share vision and mission. Effectively communicate outcomes, data analysis, complex processes and action plans to division/unit staff, corporate partners, and external customers
  • Twenty-four hour accountability of Medicare Advantage Appeals; including assuring the development of teams which are focused on exceeding the identified objectives through the following: team building sessions, team work facilitation, committee opportunities, and leadership opportunities
  • Coordinate and implement processes which require and enhance staff accountability by providing direct reports and staff with guidance and educational tools in order to assure compliance with departmental audits. In collaboration with other units and divisions, establish guidelines that quantify measurable care management value, benefit, and outcomes
  • Identify, develop, and implement division/department projects which are focused on quality, utilization, process and/or outcome improvements. Identify industry benchmarks through scientific research and literature searches on order to assure Medical Management & Policy exceeds industry standards
  • Develop new policies, procedures and workflows, and revise existing policies, procedures and workflows in order to ensure the efficient and effective operations of the Medicare Advantage appeals process. Develop and implement action plans designed to achieve and enhance compliance to accreditation standards. Work in concert with all corporate divisions and departments to develop strategies supportive of the corporate mission and vision and strategic plan
  • Actively involved in MM&P and MA Appeals operational performance in relation to monthly STARS results. Critical responsibility to achieve maximum STARS ratings which has financial impact to Highmark, Inc is to conduct tracking, trending and process improvement for operational processes that impact STARS performance
  • Conducts all auditing activities for assigned area; trends appeals and facilitate meetings to review data for process/product improvements
  • Collaboration with interdepartmental work groups i.e. Compliance and Quality, Operations and Physician Advisors
  • Collaboration with Highmark’s Provider Network
  • Collaboration within interdepartmental work groups i.e. Care Management Systems, Provider Services, Medicare C&D Compliance, Pharmacy, Quality Improvement, Product staff, Provider Reimbursement and Contracting
  • Ability to interact with external customers and providers
  • Ability to analyze data, measure outcomes and develop action plans
  • Highly effective interpersonal skills
  • Ability to intervene in crisis situations and multi-task
  • Excellent computer and software knowledge and skills
  • Demonstrate proficient Project Management skills
17

Appeals Manager Resume Examples & Samples

  • Provide expertise or general claims support to teams in reviewing, researching, investigating, negotiating, processing and adjusting claims
  • Manages and is accountable for professional employees and/or supervisors
  • Impact of work is most often at the local level
  • Flexible and able to adapt to change
  • Ability to build professional relationships
18

Appeals Manager Resume Examples & Samples

  • Oversees the unit and staff members reviewing disability and workers compensation claims; guides staff through appeals process; supports the appeal process by partnering closely with Legal and external vendor partners
  • Identifies continuous quality improvement measures through appeal result analysis while partnering with the operations team ensuring best practices are met
  • Makes recommendations on training needs; develops training curriculum; and provides training and one-way coaching as needed
  • Monitors changes to the ERISA legislation; incorporates workflow changes into the process as defined in legislative changes
  • Ensures effective process management; ensures accuracy of final customer deliverables resulting in reduction of errors, increased productivity and customer satisfaction
  • Gathers, prepares, and monitors operations and financial statistical data for reporting provided to the client
  • Participates on client calls as required
  • Ensures appropriate and timely handling of legal and client remands; handles client escalations with timely and appropriate resolutions
  • Ensures appeal requests are managed timely6 and follow the ERISA regulations or client plans; ensures accurate appeal decisions are made by the appeals specialists
  • Identifies areas to minimize risk of fines, penalties, or errors and omissions
  • Ensures accurate communications are sent to employees, clients, and attorneys
  • Administers company personnel policies in all areas and follows company staffing standards and training recommendations
  • Interviews, hires and establishes colleague performance development plans; conducts colleague performance discussions
  • Excellent knowledge of disability claims management practices
  • Knowledge of ERISA regulations
  • PC literate, including Microsoft Office products
  • Leadership/management/motivational skills
  • Ability to meet or exceed Performance Competencie
19

Manager of Denials & Appeals Resume Examples & Samples

  • Collaborates with Finance, revenue cycle personnel, physicians, contracting team, case managers, and payers to appeal denials and mitigate trends
  • Keeps up-to-date on issues surrounding commercial and government payer regulations and processes around audits and denials, and implementing policies and procedures to assure compliant and accurate billing practices
  • Oversees case management team with maintaining open communication with payers and negotiating concurrent billing status reflective of patient level of care. Jointly maintains with Finance the tracking of denials, the level in the appeals process for each claim, financial impact of outcome of denials, reason for the denial and the upheld and overturned decisions
  • Responsible for analyzing and interpreting trends associated with denials and appeals to effectively manage reimbursement and build strategies for mitigating future denials
  • 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. Utilize written and verbal exchange of clinical information for the purpose of providing clear, unambiguous clinical review to payer
  • Facilitate communication between attending physician and medical advisor to insurer, when this level of communication is indicated to avoid authorization denial
  • Serve as a resource to Finance, Patient Access, Coding, Patient Accounts and various clinical departments in clarifying hospital status for specific accounts. Stays concurrent on and provides education on regulatory changes as it relates to level of care determination, discharge planning, and appeals and denials
  • Perform retrospective record reviews providing clinical updates to insurer in a timely manner. Utilize written and verbal exchange of clinical information for the purpose of providing clear, unambiguous clinical review to payer for purposes of payment determination
  • Perform prebill audits on all inptatient stays that do not meet the 2 midnight rule and assure the proper level of care. Notify finance of outcome of audit
  • Develop and track indicators and report trends to Director and CFO. Provide feedback to department regarding changes in third party expectations as well as any trends in denial activity
  • Perform other duties as assigned. Display flexibility, cooperation, characteristics of a team member and excellent communication skills
  • Registered Nurse licensed to practice in the Commonwealth of Massachusetts required
  • Bachelor's degree in Nursing or Healthcare field required
  • Experience with third party claim resolution processes including denials and appeals management, adjudication of claims required
  • Experience with interqual or millimen criteria required
  • Knowledge of ICD-10 coding methodology
  • Relevant management experience or experience in presenting issues, outcomes and recommendations to Senior managers of an organization
  • Positive attitude, pleasant, professional demeanor with patients, physicians, fellow employees and insurance representatives
  • Ability to work independently and effectively in a fast paced environment
  • Ability to work productively in a stressful environment and effectively handles multiple projects and changing priorities
  • Flexibility in a fast changing environment and able to perform as a team member
20

Manager, Denials & Appeals Resume Examples & Samples

  • Ensure that all denials and appeals are processed in accordance with Federal, State and NCQA time frames and other contractual legal requirements
  • Identify trends within denials and appeals and provide results to internal committees, CMS and the State as required by contract
  • Serve as the point of contact for any issues or questions related to denials and appeals for various external agencies, including state, local and federal governments, local community and the public
  • Integrate federal and state law changes to denials and appeals into company's regulatory system
  • Recommend solutions and ensure issues are corrected and corrective measures are implemented to prevent recurrence
  • Ensures that all internal and external audit indicators are met
  • Timely and consistently reports project status to upper management/leadership
  • EDUCATION, SKILLS & EXPERIENCE
21

Manager, Medicare Appeals & Grievances Resume Examples & Samples

  • Direct the daily Medicare appeals and grievance activities to ensure best in class resolution and service as well as ensure compliance with policies, procedures and regulation; includes managing assigned member appeals and formal complaint cases from documentation through resolution
  • Coach, develop, and mentor staff in the accurate and timely management of Appeals and Grievances providing on-the-spot technical support and direction
  • Supervise and partner with the Medicare Advantage Appeals and Grievances Business Compliance Lead to ensure compliance with CMS
  • Assist in new hire and ongoing training programs and ensure Appeals and Grievance staff are knowlegable of policies and procedures
  • Ensure timely communication with Director on any issues having the potential to impact operation or organization
  • Serve as liaison and lead resource for both internal and external customers while building positive working relationships
  • Coordinate and participate in CMS and non-CMS mock auditing and data collection activities as needed
22

Grievance & Appeals Manager Resume Examples & Samples

  • Manage work to produce customer value by planning and forecasting, setting objectives and priorities, establishing goals, clarifying accountabilities, assigning work and utilizing management and financial controls
  • Manage inventory levels, identifying risks and opportunities to improve efficiency and timeliness outcomes
  • Develop quality controls to ensure Grievance and Appeals workloads are accurately resolved in accordance to CMS guidance
  • Manage levels of performance and assist with employees’ professional growth by planning and building an effective organization; communicating effectively; coordinating with others; maintaining employee morale; motivating, recognizing and rewarding others; coaching and developing others; managing performance and engaging in self-development
  • Manage business and public relationships and situations to obtain better business outcomes; communicate effectively and coordinate with others
  • Effectively drive change and execute on set priorities; set policies and procedures and manage creativity and innovation
  • Typically has shared responsibility for budget at the cost center level