Manager of Appeals

Richmond VA 23233

Job Description

Manages all Appeal activities, staff and reporting within an assigned unit of Magellan Health based on federal, state, accreditation and contractual agreements and standards.
  • Manages appeal processes so that members and providers are well served, customers are satisfied and regulations and accreditation standards are met. 
  • Organizes volume of work and work-flow so that performance standards and proper procedures for appeals resolution are consistent with client, state and federal requirements. 
  • Coordinates and distributes first, second and third level appeal request assignments. 
  • Reviews proposed appeal letter language for completeness and consistency with customer and regulations and oversees the determination for clinical or administrative appeal. 
  • Supervises staff; conducts performance reviews, sets unit standards, and scorecard goals.
  • Manages the data gathering and analysis of reports regarding appeal and complaint activity as well as preparation for appeals audits. 
  • Provides employee training, monitor QI activities of appeals department, and assist in the development of department workflows and implementations.
  • Responds to member, provider, and client inquiries regarding status, process and outcome of appeals. 
  • Consults with clinical managers on problem cases and interface with case managers, clinical supervisors, account managers and other Magellan employees in resolving denial and appeal questions.

General Job Information

Title

Manager of Appeals

Grade

25

Job Family

Quality Group

Country

United States of America

FLSA Status

United States of America (Exempt)

Recruiting Start Date

2/11/2020

Date Requisition Created

2/4/2020

Work Experience

Healthcare, Management/Leadership, Utilization Management

Education

Associates: Nursing, Bachelors: Healthcare

License and Certifications - Required

License and Certifications - Preferred

LCSW - Licensed Clinical Social Worker - Care Mgmt, RN - Registered Nurse, State and/or Compact State Licensure - Care Mgmt

Other Job Requirements

Responsibilities

  • 5+ years' appeals experience.
  • Demonstrated ability to manage processes and staff.
  • Knowledge of appeal handling and clinical protocols.
  • Ability to work under time pressures, complete reports and work across departments to meet deadlines for customer deliverables.
  • Ability to work with software systems for data capture of appeals and reporting of findings. 
  • Strong written and verbal communication skills. 
  • Knowledge of accreditation requirements related to appeal processing.

Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply and attest to the security responsibilities and security controls unique to their position.

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