Appeals Manager

CNSI and Kepro are now Acentra Health! Acentra Health exists to empower better health outcomes through technology, services, and clinical expertise. Our mission is to innovate health solutions that deliver maximum value and impact.

Lead the Way is our rallying cry at Acentra Health. Think of it as an open invitation to embrace the mission of the company; to actively engage in problem-solving; and to take ownership of your work every day. Acentra Health offers you unparalleled opportunities. In fact, you have all you need to take charge of your career and accelerate better outcomes - making this a great time to join our team of passionate individuals dedicated to being a vital partner for health solutions in the public sector.

Acentra is looking for a Appeals Manager to join our growing team.

Job Summary:

The purpose of this position is to oversee the clinical team and to manage and complete assigned work plan projects to comply with performance standards. This role will oversee the Mediation and Appeals Team who manage a caseload of assigned cases to ensure that mediations are scheduled, mediations are performed within timelines and data is entered into QiRePort and the Mediation Tracker within prescribed timelines. The Clinical Manager coordinates with the Directors and Program Leads on decisions and issues, and communicates with the team, NC MCD and the Attorney General's Office as appropriate regarding determinations and other clinical matters. The Clinical Manager also develops and leads clinical staff in activities to facilitate and support clinical, quality, and cost-effective outcomes.

Job Responsibilities:

• Oversee, coordinate, and monitor all Clinical team activities.
• Ensure adequate staffing and contractual service levels are adhered to by implementing and monitoring clinical staff productivity and performance indicators. Maintains effective team member relations.
• Leads team members in improving skills, creativity, and problem-solving.
• Work with management team to develop and enhance the operational structure including skill set requirements, gap analysis, and training using workforce planning.
• Manages and completes assigned work plan objectives and projects on a timely basis.
• Provide advice and assistance to leaders in the planning, implementation, and evaluation of modifications to existing operations, systems, and procedures. Collaborate with leadership in the development of new and enhanced products and services.
• Represents the clinical department by participating on committees, task forces, work groups, and multidisciplinary teams.
• Maintains professional relationships with provider community and external customers and identifies opportunities for improvement.
• Participates in the development of policies and oversees clinical staff activities to ensure compliance with regulatory and accrediting standards, quality assurance and inter-rater reliability.
• Provides reports of compliance and other activities.
• Conducts mediations at the request of beneficiaries who have had an adverse decision for all programs. and compliance.
• Identifies and documents specific quality indicators for monitoring and tracking the reasons for adverse appeal decisions.
• Oversees and maintains mediation records and reports using a tracker that tracks all mediation/appeal requests, dates of the requests, number of requests completed and not completed, and outcomes.
• Communicates and coordinates with OAH and the Attorney General's Office.
• (Atrezzo) Supports analysis of the Mediation and Appeals process for quality improvement by maintaining information in database for tracking/trending all decisions, dates, issues and outcomes.
• Duties related to maintenance of internal databases.
• Performs other duties as assigned by management.
• Proactively anticipates and works to mitigate problems that could result in customer dissatisfaction or failure to deliver contracted services.
• Enters Results of Mediation assessment requests into QiRePort as applicable.
• Enters appeal results into QiRePort as applicable.
• Communicates with Mediations Centers to schedule mediations within timelines.
• Research cases in appeal to prepare for mediation to include PCG records as well as independent assessment(s), supporting docs and comm log notes within QiRePort.
• Assures contract compliance by meeting all contractual, legal, and regulatory requirements pertaining to this role.
• Meets expectations in Quality Assurance benchmarks.
• Meets expectations in Quality Control measures.
• Is knowledgeable of NC Medicaid Recipient Due Process Rights and Prior Approval Policies and Procedures in order to maintain appropriate systems for implementation.
• Works to negotiate settlements during mediations.

Required Qualifications/Experience

• Bachelor's degree or equivalent experience.
• 5+ years of medical appeals experience.
• 5+ years staff/workload management experience.
• Demonstrated proficiency in MS Office applications.
• Ability to maintain a positive attitude and contribute both as an individual and a team member to achieve the goals of the department.
• Ability to professionally respond to change and handle multiple and changing priorities with sometimes conflicting deadlines.
• Knowledge and willingness to become a subject matter and thought leader for designated program(s).

Why us?

We are a team of experienced and caring leaders, clinicians, pioneering technologists, and industry professionals who come together to redefine expectations for the healthcare industry. State and federal healthcare agencies, providers, and employers turn to us as their vital partner to ensure better healthcare and improve health outcomes.

We do this through our people.

You will have meaningful work that genuinely improves people's lives across the country. We are a company that cares about our employees, and we give you the tools and encouragement you need to achieve the finest work of your career.

Benefits

Benefits are a key component of your rewards package. Our benefits are designed to provide you with additional protection, security, and support for both your career and your life away from work. Our benefits include comprehensive health plans, paid time off, retirement savings, corporate wellness, educational assistance, corporate discounts, and more.

Compensation

The pay range for this position is $72,000.00/annually - $75,000.00/annually.

"Based on our compensation program, an applicant's position placement in the pay range will depend on various considerations, such as years of applicable experience and skill level."

Thank You!

We know your time is valuable and we thank you for applying for this position. Due to the high volume of applicants, only those who are chosen to advance in our interview process will be contacted. We sincerely appreciate your interest in Acentra Health and invite you to apply to future openings that may be of interest. Best of luck in your search!

~ The Acentra Health Talent Acquisition Team

Visit us at Acentra.com/careers/

EOE AA M/F/Vet/Disability

Acentra Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran or any other status protected by applicable Federal, State or Local law.