Appeals Supervisor - Schenectady
MVP Health Care - Schenectady, NY

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Oversees the daily operations of the Appeals Department, including assessing including internal and external member and provider appeal and complaint cases for trends and potential service improvement opportunities. Oversees the investigation and resolution of regulatory complaints and external appeal review requests. Oversees operations of Second Level Appeals Committee meetings. Provides direct daily supervision to appeal coordinators. Interviews, screens, and recommends department hires. Orients, evaluates, and counsels staff as needed. Handles policy and employee issues in conjunction with Human Resources. Supervises the member and provider appeal functions for lines of business. Reviews and performs quality control for all components of appeal cases. Assures regulatory and accreditation requirements are fully met. Focuses on timely and accurate tracking and trending of data, assessing opportunities for service and process improvement. Prepares monthly/annual reports and data analysis trending/process improvement reports. Participates in the presentation of departmental reports. Attends interdepartmental meetings related to appeal functions including CMS Stars and Medicare Experts. Conducts and performs quarterly audit of appeals for MVP s delegated entities with summary and corrective action plan. Works in conjunction with the Appeals Manager on special projects. Performs other duties as assigned. Minimum Education: AA or BS degree in Business or Health related field or comparable experience in a health insurance industry. Minimum Experience: Minimum 3 years experience in Business or Health related field, preferably in a customer service and/or health insurance environment. Required Skills: Strong background in Medicare benefit coverage, rules, and regulations. Knowledge of the business systems and applications, including Facets, Macess, Microsoft Office. Excellent verbal and written skills, including strong conflict resolution skills. Strict attention to detail and adherence to project timeframes. Working knowledge of medical terminology necessary. Ability to sit at a workstation for extended periods of time.

Requirements:

About this company
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MVP Health Plan covers about 650,000 most valuable people. Also known as MVP Health Care, the company provides health insurance and employee...