Appeals Clinical Manager
Looking for a way to make an impact and help people?
Join PacificSource and help our members access quality, affordable care! PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.
Accountable for the effective management of appeals clinical staff. Responsible for hiring, training, coaching, counseling, and evaluating team member performance. May be called upon to perform routine day-to-day program functions. Actively participate in program development and implementation. Supervise and provide guidance to direct reports and other department staff regarding company policies, procedures, and operations. Manage the quality and productivity of team tasks and workflow as they relate to both assigned functions and the overall effectiveness of the Health Services team. Work to resolve issues and improve processes and outcomes.
Essential Responsibilities:
- Take a leadership role in the development, implementation, and ongoing operation and maintenance of assigned programs, services, or functions.
- Improve the performance of the department through effective oversight and coaching of team members, managing team performance and improving processes and outcomes. Monitor daily workflow and caseloads and other work processes of team to assure appropriate distribution and processing of tasks.
- Responsible for the orientation and training of new hires.
- Provide ongoing supervision, training, evaluation, and leadership to assigned team members. This may include annual reviews, involvement in promotions and/or terminations of employees.
- Participate in hiring decisions in concert with Appeals and Grievance Director and HR.
- Monitor and evaluate team assignments relating to volumes, timelines, accuracy, customer service, and other quality and performance measures, and take actions as appropriate.
- Assist with process improvement and work with other departments to improve interdepartmental processes. Utilize LEAN methodologies for continuous improvement. Monitor key performance indicators and identify improvement opportunities.
- Serve as liaison with other PacificSource departments or community partners to coordinate optimal provision of service and information. Serve on various internal and external committees as required or designated. Document and report any pertinent communications back to the team or department.
- Utilize and promote use of evidence-based medical criteria.
- Maintain modified caseload consistent with assigned responsibilities.
- Facilitate investigation and resolution of process-related issues as needed. Facilitate conflict resolution, including interfacing with affected departments and individuals, as appropriate.
- Oversee and assist in providing exceptional service and information to members, providers, employers, agents, and other external and internal customers.
- Provide backup to other departmental teams or management staff, as needed.
Supporting Responsibilities:
- Meet department and company performance and attendance expectations.
- Relate new or revised policies, procedures and/or processes to team members to ensure they have the most up-to-date and current information.
- Facilitate team operations by discussions through the sharing of information and knowledge, identification of teamwork issues, development of problem-solving recommendations, and recommendations of standardizing Health Services operations.
- Represent the Appeals and Grievance Department, both internally and externally, as requested by Appeals and Grievance Manager and/or Director.
- Perform other duties as assigned.
Work Experience: A minimum of five years clinical experience required. Minimum of three years direct health plan experience in the following areas: utilization management, grievance and appeal, or claims review strongly preferred. Prior supervisory experience preferred.
Education, Certificates, Licenses: Registered Nurse/Licensed Social Worker with current appropriate unrestricted state license. Within 6 months of hire licensure may need to include Oregon, Montana, Idaho, Washington and/or other states as needed.
Knowledge: Knowledge of health insurance and state mandated benefits. Thorough knowledge and understanding of medical procedures, diagnoses, care modalities, procedure codes (including ICD-10, HCPC CPT codes). Effective adult education/teaching and/or group leadership skills. Ability to deal effectively with people who have various health issues and concerns. Strong analytical and organizational skills with experience in using information systems and computer applications. Flexible to meet the departments changing needs Ability to develop, review, and evaluate utilization and case management reports. Good computer skills including experience with Word, Excel, and PowerPoint. Ability to use audio-visual equipment. Ability to work independently with minimal supervision.
Competencies:
Building Trust
Building a Successful Team
Aligning Performance for Success
Building Customer Loyalty
Building Strategic Work Relationships
Continuous Improvement
Decision Making
Facilitating Change
Leveraging Diversity
Driving for Results
Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5% of the time.
Skills: Accountable leadership, Collaboration, Communication (written/verbal), Critical Thinking, Decision Making, Influencing, Listening (active), Organizational skills/Planning and Organization
Our Values: We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:
- We are committed to doing the right thing.
- We are one team working toward a common goal.
- We are each responsible for customer service.
- We practice open communication at all levels of the company to foster individual, team and company growth.
- We actively participate in efforts to improve our many communities-internally and externally.
- We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.
- We encourage creativity, innovation, and the pursuit of excellence.
Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.
Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.
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