GENERAL SUMMARY:

The Clinical Manager, Provider Appeals supports appeals team members to plan, direct, evaluate, coordinate, and manage the activities associated with the Provider Appeals as it relates to key HAP initiatives and service excellence.  Ensure the efficient and timely processing of provider appeals, for all product lines (HMO, AHL, and Medicare Advantage (MA), Medicaid, and Duals) in accordance with internal HAP policies.  Coordinate with the other Appeals and Grievance department managers and other team members on provider appeals ensuring compliance with regulatory mandates including NCQA, Department of Labor (DOL) and Center for Medicare/Medicaid Services (CMS).  Maintain formal history of provider appeals and the medical component of Member appeals to utilize for process improvements, forecasting and planning for people, resources, and technology.

Develop skills and competencies of direct reports to maximize employee engagement, increase productivity and create an environment of teamwork and commitment; coach and counsel people to exceed performance levels through professionalism, positive relations, and timeliness in all customer contacts. 

PRINCIPAL DUTIES AND RESPONSIBILITIES:

Provide team member direction and management for Provider Appeals which includes day-to-day operations, the appropriate coaching and development, planning, staffing and coordination of activities as they pertain to divisional and corporate goals, strategies, and objectives. Monitor the written responses to HAP provider appeals.  Determine training, policy, procedure, and benefit needs relating to verbiage used in these determinations.Monitor determinations for Member appeals with a medical component to ensure these responses meet the regulatory requirements for every product line.Assist with follow-up for all Member appeals with a medical component sent to and/or overturned by an external independent review organization, for possible opportunities within Provider Network Management.  Maintain an on-going relationship with support departments and respective Medical Directors for the resolution of sensitive and routine problems relating to HAP providers and policies and procedures.Supply necessary internal control oversight information regarding system changes affecting the Provider Appeal and Member appeals with a medical component processes to ensure proper system testing, system documentation, user training, etc., is performed prior to implementation or upgrade.Develop and review department operational policies and procedures.Collaborate with Health Care Management leadership and the provider appeals team to identify regulatory and quality issues. Develop, communicate, and oversee the immediate implementation of corrective action requirements as needed.Maintain professional relationships with the provider community to optimize the member experience.  Analyze utilization trends to identify opportunities for improvement.  Meet with appropriate HAP leadership to review utilization trends and reports. Assist the Clinical Director, Appeals and Grievance with preparing and administering the annual budget based on the department’s activities and forecasts. Develop tactics to improve operational efficiencies and retaining expenses within budget. Provide analysis for variances as well as prepare various budgetary reports as requested by leadership.Cross support peer managers in appeals and grievance where needed to assure smooth operations for other operations in the Appeals and Grievance department. Other duties assigned by the Clinical Director, Appeals and Grievance.

 

EDUCATION/EXPERIENCE REQUIRED:

Registered Nurse with current Michigan licensureBachelor’s Degree in Healthcare, Business Administration/Management or related field. An additional fours (4) years of related relevant experience may be considered in lieu of degree.Minimum of three (3) years managed care experience with emphasis on program management and improvement in health care operationsStrong experience working in the managed care industry, including familiarity with performance/quality improvement, business operations, physician organizations, medical management, and quality areas. Demonstrated use of performance improvement and program management methodologies. Additional Information Organization: HAP (Health Alliance Plan) Department: Medical Appeals Henry Ford Health Location: HAP (Health Alliance Plan)  Shift: Day Job Union Code: Not Applicable