Appeal Resolution Manager jobs in Mobile, AL

Appeal Resolution Manager manages the grievance process to review, investigate, document, process, negotiate, and resolve disputed medical, insurance, and other claims. Oversees work activity that is compliant with all regulatory guidelines and policy protocols. Being an Appeal Resolution Manager allocates team resources to ensure an effective and balanced case workload. Applies industry standards and uses best practices in the preparation of legal briefs. Additionally, Appeal Resolution Manager may represent the organization at hearings. Requires a bachelor's degree. Typically reports to a senior manager or head of a unit/department. The Appeal Resolution Manager manages subordinate staff in the day-to-day performance of their jobs. True first level manager. Ensures that project/department milestones/goals are met and adhering to approved budgets. Has full authority for personnel actions. To be an Appeal Resolution Manager typically requires 5 years experience in the related area as an individual contributor. 1 - 3 years supervisory experience may be required. Extensive knowledge of the function and department processes. (Copyright 2024 Salary.com)

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Resolution specialist
  • SUNSHINE ENTERPRISE USA LLC
  • Orange, AL FULL_TIME
  • CompanyOverview : Sunshine Enterprise is an industryleading Staffing and RecruitmentFirm. Our clients are fortune 500 companies high growth startupcompanies government and private equity firms and lead professionalservices firms.

    Asa leading force in the business landscape we take pride in bringing together great people and greatorganizations by fostering a work environment that valuescreativity diversity and growth.

    Ifyoure ready to embark on a rewarding career journey with a companythat prioritizes its employees explore our current jobopportunitiesbelow.

    JobSummary The Grievance ResolutionSpecialist coordinates the Grievance and Appeal resolution processresponds to verbal and written Grievances and Appeals from membersand / or providers relating to member eligibility and benefitscontract administration claims processing utilization managementdecisions and pharmacy and vision decisions.

    The incumbent hasfrequent external contact with members and families healthcareproviders health networks thirdparty administrators and regulators.

    The incumbent collaborates with internal departments such asCustomer Service Provider Operations Pharmacy and MedicalManagement to identify factors necessary for the optimal resolutionof Grievances and Appeals.

    PositionResponsibilities

    • Participatesin a missiondriven culture of highquality performance with a memberfocus on customer service consistency dignity andaccountability.
    • Assiststhe team in carrying out department responsibilities andcollaborates with others to support short and longtermgoals / priorities for thedepartment.
    • Maintainsadequate information in CalOptima Health s systems; ensures datacollection summarization integration and reporting which includescase creation and management and events / activitytracking.
    • Gatherspertinent information regarding the grievances and appeals receivedincluding but not limited to member or provider concerns supportinginformation related to initial decisionmaking new informationsupporting the grievance or appeal or supplemental informationrequired to evaluate grievances and appeals within regulatoryrequirements.
    • Coordinatesand / or participates in case discussion with operational experts toresult in a final case disposition asneeded.
    • Evaluatescase details proposes recommendations or makes decisions asapplicable; ensures organization decision is implemented accordingto the Grievance and Appeals policies and caseresolution.
    • Developsresolution letters and correspondence to members andproviders.
    • Communicateswith internal and external customers to ensure timely review andresolution of grievances orappeals.
    • Initiatesreferrals to Quality Improvement department as applicable andfacilitates responses to members according to CalOptima Healthpolicy.
    • Assistswith Health Networks complianceprocess.
    • Identifiestrends and root cause of issues; proposes solutions or escalatesongoing issues tomanagement.
    • Meetsperformance measurement goals for Grievance and Appeals ResolutionServices.
    • Completesother projects and duties asassigned.
    • Completesother projects and duties asassigned.

    Possesses the AbilityTo :

    • Exercisediscretion in processing confidentialinformation.
    • Identifycritical issues and make recommendations or decisions by usingcritical thinkingskills.
    • Documentand present case research findings and formulate resolutionletters.
    • Communicateclearly and concisely both orally and inwriting.
    • Utilizecomputer and appropriate software (e.g. Microsoft Office : WordOutlook Excel PowerPoint) and job specific applications / systems toproduce correspondence charts spreadsheets and / or other informationapplicable to the positionassignment.

    Experience &Education

    • HighSchool diploma or equivalentrequired.
    • 1year of experience in any of the following areas : Grievances andAppeals Claims Regulatory Compliance Customer Service or relatedfieldsrequired.
    • Anequivalent combination of education and experience sufficient tosuccessfully perform the essential duties of the position such asthose listed above is alsoqualifying.

    PreferredQualifications

    • Associatedegree in Business Health Care Administration or relatedfield.
    • Bilingualin English and in Arabic Farsi Chinese Korean Spanish orVietnamese.

    Knowledgeof :

    • Stateand Federal regulations regarding the healthcareindustry.
    • ManagedCare industry health care MediCal / Medicaid and Medicareprocesses.
    • Appealsand Grievances operating procedures and processes stronglypreferred.

    At SunshineEnterprise USA LLC we firmly believe that our employees are theheartbeat of our organization and we are happy to offer thefollowing benefits :

    Competitive pay& weekly paychecks

    Health dentalvision and life insurance

    401(k) savingsplan

    Awards andrecognition programs

    Benefiteligibility is dependent on employment status.

    SUNSHINEENTERPRISE USA LLC is an Equal Opportunity Employer and does notdiscriminate on the basis of race or ethnicity religion sexnational origin age veteran disability or genetic information orany other reason prohibited by law inemployment.

    Last updated : 2024-02-22

  • 1 Month Ago

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Manager
  • Arby's
  • Fairhope, AL TEMPORARY,PART_TIME,FULL_TIME,OTHER
  • ```Overview:```We are seeking an experienced and motivated Manager to join our team. As a Manager, you will be responsible for overseeing the daily operations of our establishment and ensuring excepti...
  • 19 Days Ago

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Manager
  • Arby's
  • Daphne, AL PART_TIME,FULL_TIME,OTHER,TEMPORARY
  • ```Overview:```We are seeking an experienced and motivated Manager to join our team. As a Manager, you will be responsible for overseeing the daily operations of our establishment and ensuring excepti...
  • 19 Days Ago

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Manager
  • Arby's
  • Gulf Shores, AL FULL_TIME,PART_TIME,OTHER,TEMPORARY
  • ```Overview:```We are seeking an experienced and motivated Manager to join our team. As a Manager, you will be responsible for overseeing the daily operations of our establishment and ensuring excepti...
  • 20 Days Ago

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Manager
  • Baumhowers of Foley LLC
  • Foley, AL FULL_TIME
  • Description Baumhower’s Victory Grille Restaurant Managers Baumhower’s Victory Grille is a part of the Aloha Hospitality International restaurant group. Aloha Hospitality is an Alabama based company w...
  • 20 Days Ago

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Manager
  • Buffalo Wild Wings Foley
  • Foley, AL FULL_TIME
  • Introduction:We are seeking a skilled and experienced Assistant Manager to join our team and assist in the day-to-day operations of our business. The Assistant Manager will be responsible for managing...
  • 21 Days Ago

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0 Appeal Resolution Manager jobs found in Mobile, AL area

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Internal Revenue Agent / Senior Revenue Agent (Examiner)-12 Month Roster AMENDED
  • Department Of The Treasury
  • Mobile, AL
  • Duties WHAT IS THE LARGE BUSINESS AND INTERNATIONAL DIVISION? A description of the business units can be found at: https...
  • 3/28/2024 12:00:00 AM

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Internal Revenue Agent - 12 Month Roster
  • Department Of The Treasury
  • Mobile, AL
  • Duties WHAT IS THE LARGE BUSINESS AND INTERNATIONAL(LB&I)DIVISION? A description of the business units can be found at: ...
  • 3/28/2024 12:00:00 AM

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Student Worker - USA Dining Marketing - Univ. South Alabama
  • ARAMARK Refreshment Services, Inc.
  • Mobile, AL
  • Job Description Assist USA Dining Marketing Team in informing both parents and incoming students about the benefits of m...
  • 3/28/2024 12:00:00 AM

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Store Manager
  • Big Tex Trailer World
  • Mobile, AL
  • Job Description Job Description Summary Maintain all aspects of the store operation including safety, sales, service, pa...
  • 3/27/2024 12:00:00 AM

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Supervisory Internal Revenue Agent (12 month roster) AMENDED
  • Department Of The Treasury
  • Mobile, AL
  • Duties WHAT IS THE LBI - LARGE BUSINESS AND INTERNATIONAL DIVISION? A description of the business units can be found at:...
  • 3/27/2024 12:00:00 AM

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Registered Nurse, Home Health Full Time
  • CenterWell Home Health
  • Mobile, AL
  • Become a part of our caring community and help us put health first T As a Home Health Registered Nurse, you will: Provid...
  • 3/27/2024 12:00:00 AM

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Peer Specialist, Part Time (Weekends)
  • AltaPointe Health Systems
  • Mobile, AL
  • The Behavioral Health Crisis Center is strategically placed in Mobile County with easy access for the area with the high...
  • 3/27/2024 12:00:00 AM

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Outside Sales Account Manager
  • Würth MRO, Safety, & Metalworking
  • Mobile, AL
  • Here at Würth MRO, Safety & Metalworking (MSM) Division, we are a growing company, looking to have competent, career foc...
  • 3/25/2024 12:00:00 AM

Mobile (/moʊˈbiːl/ moh-BEEL; French pronunciation: ​[mɔ.bil]) is the county seat of Mobile County, Alabama, United States. The population within the city limits was 195,111 as of the 2010 United States Census, making it the third most populous city in Alabama, the most populous in Mobile County, and the largest municipality on the Gulf Coast between New Orleans, Louisiana, and St. Petersburg, Florida. Alabama's only saltwater port, Mobile is located on the Mobile River at the head of the Mobile Bay and the north-central Gulf Coast. The Port of Mobile has always played a key role in the economi...
Source: Wikipedia (as of 04/11/2019). Read more from Wikipedia
Income Estimation for Appeal Resolution Manager jobs
$86,315 to $112,178
Mobile, Alabama area prices
were up 1.3% from a year ago

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