Team Lead, QI Clinical Appeals

Job Summary:

The Team Lead, QI Clinical Appeals is responsible for overall project management of clinical appeals and state hearings performance across all states to assure contractual, state, and accreditation compliance.

Essential Functions:

• Under the direction of the Clinical Appeals Manager, lead a team of Registered Nurses, Coordinators and clerical personnel to coordinate and monitor all aspects of the clinical appeal and state hearing processes
• Track and monitor all clinical appeals and state/fair hearings across all states
• Ensure all activities are well coordinated, efficient and effective
• Ensure staff are educated and have a thorough understanding of accreditation standards for their roles
• Ensure all activities meet regulatory, contractual, accreditation requirements
• In collaboration with the QI and Clinical Appeals Managers, generate, monitor and analyze reports related to key statistics and other reports deemed necessary
• Oversight of the audit process for clinical appeals and state hearings to ensure compliance with regulatory and accreditation standards
• Develop and implement SOPs and training tools related to all jobs
• Monitor and revise the department's orientation manual to ensure it is up-to-date with the latest processes
• Coordinate project management while collaborating with clinical staff and clerical staff to ensure desirable outcomes
• Problem solving to remove barriers in reaching clinical performance initiative goals
• Manage staffing and scheduling functions
• Maintain positive relationship with internal and external customers
• Perform any other job related instructions, as requested

Education and Experience:

• Bachelor's Degree or equivalent years of relevant work experience is required
• Three (3) years of previous management/leadership experience is preferred
• Experience with FACETS preferred
• Healthcare and/or HMO experience is preferred
• Strong communication skills and ability to work with multidisciplinary departments across the organization

Competencies, Knowledge and Skills:

• Proficient with Microsoft Office, including Outlook, Word and Excel
• Communication skills both written or verbal
• Management skills
• Prior supervisory skills
• Ability to work independently and within a team environment
• Attention to detail
• Familiarity of the healthcare field
• Knowledge of Medicaid/Medicare
• Proper grammar usage
• Time management skills
• Proper phone etiquette
• Customer service oriented
• Decision making/problem solving skills
• Leadership experience and skills
• Capable of multitasking

Licensure and Certification:

• None

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time

Compensation Range:
$72,200.00 - $115,500.00 CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type:
Salary

Competencies:
- Fostering a Collaborative Workplace Culture
- Cultivate Partnerships
- Develop Self and Others
- Drive Execution
- Influence Others
- Pursue Personal Excellence
- Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.

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