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)
To research and resolve complex claims issues which cross interdepartmental lines and communicate the outcome to providers and affected PHC managers. Develops and maintains provider training materials for all lines of business. Conducts provider trainings across PHC departmental lines in group or individual provider settings.
Education and Experience
Minimum four (4) years claims examining experience; three (3) years PHC CSR III or above claims experience and completion of PHC claims training; or equivalent combination of education and experience; College course work in business or related field preferred.
Special Skills, Licenses and Certifications
Familiarity with Medi-Cal and/or managed care claims processing. Knowledge of CPT, HCPC procedure coding, and ICD-9 diagnostic coding. Knowledge of PHC Claim Policy and Procedures, Medi-Cal provider manual guidelines, Title 22 regulations and any other required policies, procedures, regulations, and manuals. Typingspeed 30 wpm and proficient use of 10-key calculator. Valid California driver’s license and proof of current automobile insurance compliant with PHC policy are required to operate a vehicle and travel for company business.
Performance Based Competencies
Ability to analyze and research claims issues. Excellent written and oral communication skills. Ability to present statistical and technical data in a clear and understandable manner. Good organization skills. Ability to work on multiple assignments simultaneously, prioritize work and complete projects within established time frames. Use good judgment in making decisions within scope of authority and handle sensitive issues with tact and diplomacy.
Work Environment And Physical Demands
Ability to use a computer keyboard. More than 70% of work time is spent in front of a computer monitor. Ability to lift 25lbs. Periodic travel and overnight stays may be required.
All HealthPlan employees are expected to:
HIRING RANGE:
$ 65,516.97 - $ 85,170.87
IMPORTANT DISCLAIMER NOTICE
The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.
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