Job Information
Healthfirst A&G Weekend Inventory Manager in Remote, Tennessee
Duties & Responsibilities:
Prepare and plan the weekend staffs assignments and volume to ensure compliance
Triage and assign expedited appeals while helping standardize and optimize how Appeals and Grievances are routed
Manage inventory to ensure regulatory compliance for appeals processed through the weekend
Communicate and escalate cases to Medical Peer reviewers
Maintain delegated vendor relationships and ensure vendor performance and compliance measures are met
Coordinate with outside departments for case escalation, clarifications and collaboration needed for appeal resolution
Manage letter review and printing and coordinate with the mailroom for expedited printing needs
Review case change requests and cancellations including appropriate routing for follow up
Review and submit Level 2 appeals packets to the appropriate entity
Maintain knowledge of industry trends, best practices and protocols and share with other units comprising the enterprise to ensure general consistencies and enhancements
Identify trends and recommend solutions for improvement
Maintain best practices and strategically deploy approaches to meet production, compliance and quality targets to perform all Appeals & Grievances tasks
Build partnerships with business areas across and outside of operations to improve communication and responsiveness to multiple conflicting resource demands
Provide feedback and recommendations to leadership concerning staff performance
Comply with HIPAA guidelines and maintain confidentiality of member, provider, medical and departmental information.
Adhere to state and federal compliance and regulatory guidelines
Additional duties as assigned
Minimum Qualifications:
H.S. Diploma or GED
Proven work experience with appeals and grievances or a healthcare environment
Work experience demonstrating verbal and written communication skills
Experience working independently in a fast-paced environment that requires handling multiple priorities simultaneously
Willing and able to work a weekend schedule (i.e. Fri-Mon or Thurs-Sun)
Work experience using several computer applications such as Microsoft Word and Excel, corporate email and virtual filing systems (ie. Macess), and experience with care management systems, such as CCMS, TruCare and Hyland.
Preferred Qualifications:
Bachelors degree
RN or LPN strongly preferred
Experience in clinical practice with experience in appeals & grievances, claims processing, utilization review or utilization management/case management.
Demonstrated understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, Milliman or Medicare local coverage guidelines
WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.
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