Company :Highmark Inc.Job Description : 

JOB SUMMARY

This job is responsible for the daily oversight of the Appeals and Grievances staff and for all levels of internal, external and expedited processes for the Medicaid line of business.  The incumbent is accountable for all contractual and regulatory requirements and specifications for each internal and external appeal level for the Medicaid line of business. Implements processes and monitoring mechanisms that ensure the quality and timeliness of the appeals and grievance work product to ensure compliance with applicable contracts, federal and state regulatory requirements and accreditation standards.  Provides statistical summaries and trend observations.  Oversees and provides continuous monitoring of delegated entities to ensure regulatory compliance with performance standards.  The incumbent generates all reports pertaining to Appeals and Grievances as outlined in the Medicaid contract.

ESSENTIAL RESPONSIBILITIES

Perform management responsibilities to include, but are not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity.  Plan, organize, staff, direct and control the day-to-day operations of the department; develop and implement policies and programs as necessary; may have budgetary responsibility and authority.Review, both concurrently and retrospectively, the volume, type and course of appeal matters filed by members and providers.Participate in discussions on process improvements or policy changes that could reduce appeal volume.Monitor and direct activities of and provides guidance for appeal staff.Provide oversight and leadership of the appeals and grievance team ensuring that productivity is maintained/increased.  Oversee and ensure continuity among levels and types of appeals, both internal and external.Draft, review and edit policies of the department that impact operations and have significance from an appeal perspective, with particular emphasis on drafting/modifying policies for timely incorporation of new regulations or contractual requirements.Develop or refine quality assessment process for appeals staff and work product. Represent the department effectively in interactions with internal managers and external contacts, such as advocates, attorneys, regulatory personnel and personnel in other departments.Provide oversight and intervention to assure appropriate committee composition, advocate participation and stenographic transcription for appeal panels.Maintain working relationships with regulatory bodies with respect to all lines of business.Other duties as assigned or requested.

EDUCATION

Required

High School/GED

Substitutions

None

Preferred

Bachelor's Degree

EXPERIENCE

Required

5 years of appeals, investigations, resolution, and regulatory compliance in a health insurance environment3 years of managing employees that include non-exempt, exempt, and clinical staff

Preferred

None

LICENSES or CERTIFICATIONS

Required

None

Preferred

None

SKILLS

Experience in appeal practice or other area with interaction on grievances, appeals or complaints investigation and resolutionUnderstanding of federal/state regulatory process for healthcare delivery, particularly understanding of coding and reimbursement systems, risk management and performance improvementAbility to analyze and apply statutory provisions and regulations to business situationsAbility to communicate effectively and professionallyProblem solving skills and ability to plan resolutions and evaluate efficiency once implementedAbility to effectively establish work plans and set goals and provide effective follow-up

Language (Other than English):

None

Travel Requirement:

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-based

Teaches / trains others regularly

Frequently

Travel regularly from the office to various work sites or from site-to-site

Rarely

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required 

Yes

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Rarely

Lifting: 25 to 50 pounds

Never

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times.  In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. 

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability. 

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For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org

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