Appeals Supervisor Resume Samples

The Guide To Resume Tailoring

Guide the recruiter to the conclusion that you are the best candidate for the appeals supervisor job. It’s actually very simple. Tailor your resume by picking relevant responsibilities from the examples below and then add your accomplishments. This way, you can position yourself in the best way to get hired.

Craft your perfect resume by picking job responsibilities written by professional recruiters

Pick from the thousands of curated job responsibilities used by the leading companies

Tailor your resume & cover letter with wording that best fits for each job you apply

Resume Builder

Create a Resume in Minutes with Professional Resume Templates

CHOOSE THE BEST TEMPLATE - Choose from 15 Leading Templates. No need to think about design details.

USE PRE-WRITTEN BULLET POINTS - Select from thousands of pre-written bullet points.

SAVE YOUR DOCUMENTS IN PDF FILES - Instantly download in PDF format or share a custom link.

Create a Resume in Minutes

C Stehr

Clifton

Stehr

64004 Martina Ramp

Los Angeles

+1 (555) 994 5916

64004 Martina Ramp

Los Angeles

Phone

p +1 (555) 994 5916

Experience Experience

Philadelphia, PA

Appeals Supervisor

Philadelphia, PA

Langworth Inc

Philadelphia, PA

Appeals Supervisor

Working with workforce and inventory management
Work as a member advocate to focus on process improvement to identify inefficiencies and member abrasion
Assists with changes to the ALJ Review process in coordination with the AdQIC Records Management and Communications Department
Analyzing data reports to make timely decisions and effectively implementing plans
Maintain time and attendance functions/approvals and manage UPTO to UHC policies and procedures
Impact of work is most often at the team level
Adherence to hours worked and time spent resolving cases

Dallas, TX

Supervisor Appeals

Dallas, TX

Batz and Sons

Dallas, TX

Supervisor Appeals

Responsible for superior Star Rating compliance for timeliness and fairness
Guide team / department through passing CMS and internal audits
Support team with appeals processing questions / concerns
Manage team and individual performance results and provide proper coaching on performance feedback on a regular basis
Partner with Workforce Management and Appeals leadership to ensure proper staffing and prioritize daily/weekly team workload
Provide management with daily reporting on team level compliance
Lead the team to excellent quality and production results

present

Chicago, IL

Supervisor, Denials & Appeals

Chicago, IL

Kuvalis-Brekke

present

Chicago, IL

Supervisor, Denials & Appeals

present

Analyzes system data and denial reports and makes recommendations to the Managers to improve processes
Consults with AR Manager to prioritize the working of denials and maintains current denials and appeals to meet Team Health Standards
Supervises Denials and Appeals Representatives in working denials including productivity and quality of work
Works with other denials supervisors to improve the denials resolution processes across Billing Centers
Compiles and communicates issues for management intervention and works on issue resolution)
Identifies issues with existing processes and initiates process improvement
Creates local policies and maintains policies consistent with HCFS and TeamHealth policies

Education Education

Bachelor’s Degree

Iowa State University

Bachelor’s Degree

Skills Skills

Ability to build professional relationships
Flexible and able to adapt to change
Ability to make decisions and manage a team
Ability to communicate effectively
Strong written and verbal communication skills
Build strong relationships with business partners and departmental leadership team
Be a strong and engaged representative of the Part C Appeals Team in meetings
Support team with appeals processing questions/concerns
Work as a member advocate to focus on process improvement to identify inefficiencies and member abrasion
Manage to the VEPS model to exceed goals on areas such as productivity, utilization, efficiency

Create a Resume in Minutes

6 Appeals Supervisor resume templates

Read our complete resume writing guides

Supervisor Appeals & Grievance / CTM Quality Resume Examples & Samples

Coordinates, supervises and is accountable for the daily activities of team of quality professionals
Owns output at task level
Sets priorities for the team to ensure task completion
Coordinates work activities with other supervisors to ensure production goals are met
Builds strong working relationships with Operations Team
Use reporting tools to analyze data and identify trends
Provides feedback and coaching to team members
Tracks performance and addresses performance issues as needed
Must be available to work Monday-Friday 7am-6pm CST
2 + years of experience in a Supervisor, Team Lead, or SME role
2 + years of Appeals & Grievance or CTM experience
1 + years of experience with Medicare Plans
Undergraduate Degree or Higher or 2+ years of experience in CTM

Supervisor Appeals Resume Examples & Samples

Lead the team to excellent quality and production results
Manage inventory to ensure compliance guidelines are met
Communicate with appropriate parties regarding appeals and grievance issues and decisions
Analyze and identify inventory trends
May research and resolve written Department of Insurance complaints
Accountable for coordinating and supervising all aspects of team daily activities including both member and provider issues
Responsible for overall team development
* This is an in-house position in the Shelton CT office only***
Ability to work Monday - Friday 7am-5pm EST/ One day a month would need to work until 8pm EST
1+ year of SOP(Standard Operating Procedures) Review and Development experience- understand the basic premise of the SOPs you are reviewing and developing
1+ year of experience Leading/Coaching employees within a production environment
Experience with MS Word- Create, update and format documents and MS Excel – create, update, formatting, pulling data, pivot tables and updating spreadsheets
Current experience navigating multiple systems and sites to validate and process information to retrieve data
Team Capacity Planning experience is a plus- forecasting
2+ years of Medical or Insurance Claims experience
1+ year of performing Performance Management responsibilities such as reviews and corrective action

Supervisor Appeals Resume Examples & Samples

Communicates with appropriate parties regarding appeals and grievance issues, implications and decisions
May research and resolve written Department of Insurance complaints and complex or multi-issue provider complaints submitted by consumers and physicians/providers
Experience with Microsoft Word (ability to open and save documents), Excel (ability to create simple graphs and sort data), Outlook (ability to open and send emails) and PowerPoint (ability to create simple presentations)
2+ years of experience in a Supervisory or Team Lead role, preferably within the healthcare industry
Monday- Friday 8:00 am - 5:00 pm/Flexible to work weekends and Holidays when needed
1+ year of process improvement experience
1+ year of experience analyzing and solving appeals and grievances in an office setting environment using the telephone and computer as the primary instruments to perform job duties
Claims experience
Previous HR responsibilities (hire, fire, review, etc.)

Appeals Supervisor Resume Examples & Samples

Responsible for superior Star Rating compliance for timeliness and fairness
Partner with Workforce Management and Appeals leadership to ensure proper staffing and prioritize daily/weekly team workload
Reviewing all Quality defects findings on regular basis, as well as perform random or focused quality checks as needed to improve individual and departmental overall quality metrics
Work as a member advocate to focus on process improvement to identify inefficiencies and member abrasion
Manage to the VEPS model to exceed goals on areas such as productivity, utilization, efficiency
Guide team/department through passing CMS and internal audits

Supervisor, Appeals & Grievances Resume Examples & Samples

Provides daily supervision for Grievance and Appeals Unit, including coordination of backup staffing, cross-training and deployment
Performs recruiting, hiring, promotion, and performance evaluation tasks and counsels non-clinical Grievance and Appeals staff
Orients and trains new Grievance and Appeals Unit members
Continually trains Unit members concerning grievances, appeals, and provider disputes/appeals
Regularly audits work of G&amp;amp;amp;amp;amp;amp;A Specialists and reports results
Coordinates investigation and resolution of complex appeal and grievance issues
Provides approval decisions involving grievance and appeal determinations
Coordinates maintenance and updates of desktop procedures and manuals for Unit
Assists in the establishment of grievance operating procedures
Prepares reports as required and performs trend analyses
Participates in Health Plan audits as needed

Supervisor Appeals Resume Examples & Samples

Associate's Degree or High School Diploma/GED with 10+ years of equivalent work experience
Experience with MS Word including data entry and documentation creation
Experience with MS Excel including data entry, sorting, and creating/modifying spreadsheets
Experience with MS Outlook including email communications and calendar
Keyboarding skills with the ability to navigate multiple systems and sites
2+ years of hands on leadership experience in office and remote offices
Experience with Healthcare/Medical terminology
Lean experience – understanding the principles
2+ years of Project Management experience

Expedited Supervisor Appeals Resume Examples & Samples

Monitor staff and inventory to ensure compliance with procedures and internal regulatory time frames
Maintain time and attendance functions/approvals and manage UPTO to UHC policies and procedures
Manage team and individual performance results and provide proper coaching on performance feedback on a regular basis
Support team with appeals processing questions/concerns
Enhance team morale and drive engagement within team/department
Proven track record with coaching at an individual and team level resulting in improved performance

Supervisor Appeals & Grievance / CTM Quality Resume Examples & Samples

2+ years of experience in a Supervisor, Team Lead, or SME role
2+ years of Appeals & Grievance OR CTM required > Appeals experience MUST BE specific to processing appeals from health plan perspective including: understanding of the Centers for Medicare and Medicaid Services (CMS) regulatory compliance requirements for appeals processing. Grievance experience MUST BE specific to processing grievances from a health plan perspective including: understanding of the CMS regulatory compliance requirements for grievance processing OR CTM experience WHICH MUST BE SPECIFIC TO Processing Complaints Tracking Modules received from CMS from a health plan perspective. Understanding of the CMS regulatory compliance requirements for handling beneficiary complaints received by CMS
1+ years of experience with Medicare Plans

Supervisor Appeals Resume Examples & Samples

Coordinates, supervises and is accountable for the daily activities of operational team including managing and monitoring inventory
2+ years of experience in a Supervisory, preferably within the healthcare industry
Ability to work any of our 8 hour shift schedules during our normal business hours of 6am-6pm). Flexible to work weekends and Holidays when needed

Appeals Supervisor Resume Examples & Samples

Manage ALJ Review Department Clinical and Technical Appeal Consultants, including: daily work receipts for meeting the contractual timeliness standards set forth by the Centers for Medicare & Medicaid Services (CMS); individual questions of appeals issues; updating and training of staff on Medicare laws, regulations, policies and procedures changes; providing collaborated information on what new issues arise for appeal review for possible referrals; timekeeping and scheduling; performance evaluation e for quarterly bonus reviews and completion of annual employee performance evaluations; coaching and mentoring; interviewing and hiring. Monitoring daily processing of ALJ decisions and conducting appeal review for either recommendation for referral or effectuation to the MAC per policy and procedures
Provide clinical expertise and technical support to the Medical Director, ALJ Review, Agency Referral and Records Management Departments Conduct monthly ALJ Review Staff Meetings to include updates and changes to Medicare laws, regulations, policies and procedures relevant to the CMS program; or other AdQIC or ALJ Review departmental issues
Review of inquiries and clarifications received via phone, fax, or email from Medicare Administrative Contractors for disbursement to appropriate Clinical/Technical Reviewer and resolution per CMS contractual obligations
Review DAB decisions prior to disbursement to Clinical and Technical Appeal Consultants for processing
Conducts quality assurance activities and reporting for the ALJ Review Department and implements necessary preventive and corrective actions to ensure consistent applications of all laws, regulations, policies and procedures pertinent to the program
Develops Quality Work Instructions to ensure that appeals are appropriately and consistently reviewed by the ALJ Review staff
Works directly with the Medical Director, Project Director, and other AdQIC departments to assure all CMS contractual obligations and standards are met
Assists with changes to the ALJ Review process in coordination with the AdQIC Records Management and Communications Department
Participate in and support internal and external audits of operations
Develop and monitor performance goals and objectives for overall department and staff, to include achievement of monthly KPIs and completion of annual employee performance appraisals
Interview, hire, and train departmental and other AdQIC new hires
Perform others duties as assigned
Bachelor's degree from an accredited college or university and/or a clinical degree (e.g. RN, Rph, etc.)
Experience supervising a team of direct reports of Clinnical and Technical Reviewers
Four (4) years clinical experence, ulitization/case management experience or Medicare experience preferred
Three (3) years of experience supervisor preferred
Knowledge of Medicare rules, regulations and statues
Excellent organizational, interpersonal, written and verbal communications
Ability to peerform comfortably in a fast-paced, deadline oriented work environment

Appeals Supervisor Resume Examples & Samples

Associate's Degree or 4+ years of relevant work experience and High School Diploma or GED
Intermediate experience with Microsoft Word (ability to open and save documents), Excel (ability to create simple graphs and sort data), Outlook (ability to open and send emails) and PowerPoint (ability to create simple presentations)
2+ years of experience in a Supervisory or Team Lead role preferably within the Healthcare Industry
1+ years of Process Improvement experience
2+ years of previous Claims experience preferred
Previous HR Responsibilities (hire, fire, review, etc.) preferred
Previous Appeals and Grievance experience preferred
Previous experience working in a telecommuting role or virtual environment preferred

Supervisor, Provider Appeals Resume Examples & Samples

Min. 3 years experience in healthcare claims review and/or provider dispute resolution
Knowledge of InterQual standards
Knowledge of CPT/HCPC/DRG and ICD10 coding, procedures and guidelines
Comprehensive knowledge of health care customer service, regulatory requirements and Provider Appeal process
Comprehensive medical terminology and knowledge
4+ years experience in healthcare supervisory experience

Appeals Supervisor Resume Examples & Samples

Adherence to hours worked and time spent resolving cases
Analyzing data reports to make timely decisions and effectively implementing plans
Minimum of 5 years of healthcare, health plan or benefits experience required preferably in a call center environment
Minimum one year lead or supervisor experience preferred
Minimum 2 years of health benefits or health insurance appeals experience
Summary Plan Documents (SPDs) and Certificates of Coverage (COCs)
COBRA
Medicare A, B, MediGap, Supplement plans, Medicare Advantage, Medicare Part D plans
Coordination of benefits and which plan is primary - simple and complex cases (commercial plans, Medicare plans) *Pharmacy benefits including injectable medications
Understanding of health plan authorizations, including medical policy and claims payment guidelines to evaluate if appeals require clinical or administrative review
Knowledge of procedure and diagnosis coding (ICD-9, HCPCS, and CPT-4

Supervisor, Appeals & Grievances Resume Examples & Samples

Supervises staff responsible for the submission/resolution of member inquiries or grievances. Ensures resolutions are compliant
Assesses and audits business processes to determine those most effective and efficient at resolving member problems
Interfaces with corporate counterparts and member services 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 and database of correspondence and outcomes for member appeals; monitors each appeal to ensure all internal and regulatory timelines are met
3 – 4 years experience in claims review and member appeal 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)
4+ years member resolution experience

Appeals Supervisor Resume Examples & Samples

Positions in this function are responsible for providing expertise or general support to teams in reviewing, researching, investigating, negotiating and resolving all types of appeals and grievances
Analyzes and identifies trends for all appeals and grievances
May research and resolve written Department of Insurance complaints and complex or multi-issue provider complaints submitted by consumers and physicians / providers
2+ years of experience with computer and Windows PC applications (Microsoft Word, Microsoft Excel, and Microsoft Outlook), to include creating and editing documents, spreadsheets and email communication
2+ years of experience as a Team Lead and / or Supervisor role (should be comfortable giving direction, mentoring and production tracking)
Working hours 8:00 am to 5:00 pm Monday through Friday with rotating weekends
1+ years of Claims experience
1+ years of experience analyzing and solving appeals and grievances in an office setting environment using the telephone and computer as the primary instruments to perform job duties

Supervisor Appeals & Grievances Resume Examples & Samples

Bachelors in Business Administration or related field
Three (3) years’ experience in claims, utilization review, appeals or member services in a managed care environment
Thorough understanding of managed care principles and models
Thorough understanding of health services and delivery models, including hospital, physician, ancillary, home health, prescription drugs, etc
Knowledge of various managed care reimbursement methodologies
Ability to analyze and interpret data, and prepare summary reports from findings
Familiarity with DMHC, DHS, and other regulatory agency standards related to appeals and grievances
Computer skills must include experience with database programs and the IDX Managed Care application
Exceptional diplomacy skills to effectively resolve issues under sometimes tense and stressful circumstances
Able to follow strict timelines and manage multiple tasks concurrently

Appeals Supervisor Resume Examples & Samples

Supervises a team of 15-20 Resolution Analysts and Triage Associates
Coaching and implementing correction action plan when needed
Conducting reviews, huddles, and one-on-one meetings
Ensure team is compliant in their work
Working with workforce and inventory management
1+ years of experience in a leadership role (SME, Team Lead, Supervisor, Manager)
Experience with medical, dental, or vision insurance claims appeals
Available to work between the hours of 7:00 am - 6:00 pm Monday through Friday
Experience with Dental or Vision Insurance Claims
Flexible and able to adapt to change
Ability to build professional relationships
Ability to make decisions and manage a team

Supervisor of Appeals Resume Examples & Samples

Monitors and manages initial escalated issues related to daily non-authorization, appeals and provider dispute reports
Staff Management; monitors staff production and adherence to departmental standards and expectations
Facilitates the timeliness and accuracy standards adhering to client, state and federal requirements
Organizes volume of work and manages work assignments of staff
Assists with providing employee training on different specialized task processes
Assists in the development of department workflows and implementations
Consults with clinical and/or claims staff on problem cases and interfaces with all departmental staff in resolving denial, appeal and provider dispute issues
Assists in the data gathering and analysis of reports regarding appeal and provider dispute activity, as well as preparation for audits
Capable of completing non-authorization letters and processing appeals as needed
Assists schedulers in coordinating peer to peer reviews between our Physician Advisor and the requesting provider
Knowledge of the provider dispute process and assists as needed

Supervisor Appeals / Denials Resume Examples & Samples

Candidates should be positive, energetic, self-motivated and possess excellent organizational and communication skills
Experience in denials, clinical terminology, payer contracts and medical policy is required and
A current license as an LPN or RN is a must
Knowledge and/or experience in others areas of revenue cycle (PAS, HIM, PFS) is preferred

Supervisor, Denials & Appeals Resume Examples & Samples

Assists with research and development of appropriate denials procedures
Creates local policies and maintains policies consistent with HCFS and TeamHealth policies
Updates and submits for approval policies and procedures for department
Understands TeamHealth compliance plan and HIPAA regulations. Informs appropriate Manager(s), Director(s), VP(s) or Corporate when obvious inappropriate business practices are evident that may effect not only reimbursement and accounts receivable management, but also relationships with clients, hospitals, payers and legal status. This includes any noted compliance or HIPAA concerns
Run daily, weekly and monthly reports to assist identifying potential carrier, denial, or other departmental issues
Regular and reliable attendance is necessary. 7. Overtime as directed by management
Other duties as assigned by the Accounts Receivable Manager
Prior experience in managing denials resolution
Knowledge of ICD-9 and CPT-4 coding
Excellent team management skills
Proficiency with Microsoft Excel, Microsoft Word, andLotus Notes
Proficiencyin working with systems GECB ETM (experience is desirable) and & DMS
Computerliterate
Excellentfollow-up skills
Excellentorganizational skills
At least (3) Years as a Senior/Lead and preferably five years total physician billing experience with specifically two years experience in Denials and Appeals or A/R Management. BA or BS degree preferred

Appeals Operations Supervisor Resume Examples & Samples

This position is the OptumRx Appeals Operations Supervisor- responsible to lead and manage a team of appeal coordinators processing appeal medication coverage determination requests
Position provides leadership, direction, and guidance to the team to ensure appeal case processing quality, productivity, and regulatory goals and requirement are achieved
Job also entails setting a positive work environment and achieves teamwork and innovation among employees
Position also participates and provides representation for appeals team in inter - department meetings and workgroups to ensure Appeals department issues and needs are addressed
Position also participates in quality improvement and process enhancement projects
An education level of at least a high school diploma or GED or 10 years of equivalent working experience
1 year supervisory or equivalent experience leading a team of staff to achieve operational goals and managing performance
Basic proficiency with Windows PC applications (Word, Excel, & Outlook), which includes the ability to learn new and complex computer system application
Must be able to work in a team and collaborative environment
1 year experience working in the area of prior authorization and/or appeals reviewing coverage determination requests
1 year experience working or utilizing formularies, pharmacy benefits, and UM criteria
1 year experience working in an environment of UR compliance requirements
1 year customer service experience
PBM or Managed Care experience
Medicare Part D experience
Current Pharmacy Technician license OR National Pharmacy Technician Certification (PTCB)

Appeals Supervisor Resume Examples & Samples

Associate's Degree (or higher) or High School Diploma / GED with 4+ years of relevant work experience
2+ years of previous Claims experience
Previous HR Responsibilities (hire, fire, review, etc.)
Previous Appeals and Grievance experience

Supervisor Appeals Resume Examples & Samples

Lead projects as needed to improve departmental performance
Provide management with daily reporting on team level compliance
Support team with appeals processing questions / concerns
Build strong relationships with business partners and departmental leadership team
Be a strong and engaged representative of the Part C Appeals Team in meetings
Guide team / department through passing CMS and internal audits
Other functions as delegated by management
1+ year of experience in a Team Lead or Supervisor role
6+ months of healthcare experience
Familiarity with Microsoft Outlook, Excel, Word and PowerPoint with the ability to create, modify, send and save documents and correspondence
Medicare Part C Chapter 13 and 18 fluency

Supervisor, Denials & Appeals Resume Examples & Samples

Directs the processing of and monitors the resolution of claim denials
Analyzes system data and denial reports and makes recommendations to the Managers to improve processes
Evaluates carrier requirements and formulates a denials resolution strategy
Consults with AR Manager to prioritize the working of denials and maintains current denials and appeals to meet Team Health Standards
Supervises Denials and Appeals Representatives in working denials including productivity and quality of work
Monitors work of team members, maintains effective personnel relations and ensures that goals are achieved
Compiles and communicates issues for management intervention and works on issue resolution)
Identifies issues with existing processes and initiates process improvement
Works with other denials supervisors to improve the denials resolution processes across Billing Centers
Manages department within budget guidelines
Processes RAC Audit requests
Reviews specific edits listed on the Unbilled Charges Report
Reviews and analyzes specific rejection codes listed on the Denied Invoices Pending Report
Other duties as assigned by the Accounts Receivable Manager or Director of AR
Assists with research and development of appropriate denial procedures
Creates and maintains policies consistent with HCFS and Team Health policies
Understands Team Health compliance plan and HIPPA regulations. Informs appropriate Manager(s), Director(s), VP(s) or Corporate when obvious inappropriate business practices are evident that may effect not only reimbursement and accounts receivable management, but also relationships with clients, hospitals, payers and legal status. This includes any noted compliance or HIPPA concerns
Excellent knowledge of healthcare payer reimbursement for physician billing
Good team management skills
Good knowledge of Excel
Proficiency in working with systems (IDX experience is desirable)
At least (3) three years as a Senior/Lead and preferable five years total physician billing experience with specifically two years' experience in Denials and Appeals or A/R Management
Set in a high-volume, fast-paced office environment. Involves extensive computer use
Overtime may be required and can be mandated by leadership
Occasional travel to seminar or training sessions may be required

Supervisor, Appeals Resume Examples & Samples

Guides client appeal activities, advising and serving as a technical expert. Ability to leverage contract language to support decisions. Recognizes opportunities for potential claim settlements
Maintains accurate records of cause/origin, disposition, and trending of appeals. Identifies, evaluates and provides constructive feedback on risk management trends and issues as they pertain to settlements
Researches and evaluates emerging federal common laws, Circuit & District level case laws and the impacts on group disability claim appeals. Presents cases to the appeals committee, responding to questions and obtaining additional information as requested
Mentors, coaches and trains claims staff and clients regarding the appeals process, procedures and related risk management issues
Analyzes and resolves complex claim appeals and legal files
Investigates appeal completions, coordinates responses with Appeals Specialist and creates action plans and develops recommendations to improve customer satisfaction
Handles escalated appeal calls
Human Resource Mgmt - Plans, organizes, staffs, leads and controls activities pertaining to the Appeals department to include: planning projects and capital and human resource budgets; interviewing, selecting and training subordinate staff; monitoring and appraising performance of subordinates to hold them accountable for end results including human resource management; coaching and motivating subordinates; administers disciplinary action as needed; administers compensation to subordinates; and ensures the department complies with affirmative action guidelines
Key Performance Indicators, Accuracy - Monitors work progress and performance by service operational metrics and observations of staff to maintain the quality, quantity and time service of work produced by the department within established standards. Develops, implements and monitors quality assurance processes. Prepares and provides reports to management documenting the business results of the department. Reviews department reports and corrects discrepancies to avoid reporting errors. Schedules and coordinates management of peak volumes and need-driven staff allocations. Collaborates with supporting departments to resolve any service delivery, system, and/or quality issues. Utilizing appropriate business judgment and sound customer service skills, provides effective support to internal stakeholders and/or external customers. May delegate productivity, quality and/or time service monitoring functions to team leads as appropriate and provides necessary oversight to the execution of these functions. Continuously reviews process and implements change to eliminate waste
Business Leadership - Effectively represents the Appeals department as a subject matter expert within and outside of the division/operation. Interacts frequently with key external customer and internal stakeholders. Handles significant volume of escalated issues. Exercises appropriate discretion in formulating and implementing department business decisions. Works with the Law Division on any legal matters, and may participate in depositions or trials. Reviews, analyzes and takes appropriate action to resolve claims issues, attorney inquiries
Thorough understanding of claim adjudication, benefit determination, investigation, file development, legal requirements, and contract interpretation
Experience interpreting state and federal laws and technical legal language including complex benefit plans to facilitate implementation of enhancements to systems, policy and procedures to ensure quality and compliance standards are maintained
Strong analytical and planning/organizational skills
Strong human relations skills with demonstrated ability to work with both internal and external customers to resolve issues and exert influence as appropriate
Seasoned supervisory or leadership experience
May require department-specific licensure, certifications and/or designations