PURPOSE OF THE POSITION:
To manage the processes and functions that ensure compliance with all state and federal regulations and Affinity policies and procedures on member/provider appeals, and effectively oversee the work activities of staff assigned to the Appeals function.
Develops, implements and directs processes, procedures, work flows and timelines for all appeals. Evaluates and ensures timely, efficient and effective completion of all appeals-related functions and proper maintenance of all related files and records.
Assigns appeals and appeals related cases to the unit's clinical staff, ensuring appropriate allocation assignments. Ensures that assigned staff properly track all member/ provider appeals, Fair Hearings and external appeals.
Provides leadership and direction to clinical staff on the regulatory requirements surrounding appeals, including Fair Hearing and external appeal. Regularly monitors adherence to Affinity policies and standards as well regulatory requirements to assure consistent compliance with all internal and external requirements.
Prepares and analyzes appeals reports to identify trends and helps to conduct root cause analysis. Recommends initiatives and actions to Senior Manager of the CGA Unit and Affinity senior management, as appropriate, to address root causes and support improved Affinity and/or provider processes.
Assures clinical appeal staff accountability through routine observation, reporting and performance measurement, and through timely, thorough preparation of performance appraisals for direct staff reports. Prepares and conducts performance appraisals ensuring compliance with due dates. Takes appropriate action on employee issues related to job performance and professional conduct, with assistance from and in collaboration with department management and Human Resources.
In collaboration with Human Resources and department management, interviews, assesses and selects new employees for the Appeals team.
Assures effective, on-going staff training and development activities to support staff orientation, knowledge and skill enhancement, proficiency/productivity and professional growth for Appeals staff.
Oversees the Fair Hearing and external appeal processes, including the vendors that support these processes.
Establishes and maintains effective working relationships with all Affinity departments involved in appeals (specially Medical Management and Claims Departments). Ensures that clinical appeal staff support effective inter-department working relationships
Develops training manuals for appeal staff and helps maintain and keep current all policies and procedures; produces required and/or requested appeal reports for internal committees and external agencies; assists Senior Manager in developing and designing new reports, and attends meetings/presents to audiences as indicated
Provides training, information and resources to CGA and all other QM staff, Customer Service, Medical Management, Claims and other Affinity staff regarding member/provider appeal process.
Serves as a liaison between Members, Providers and Affinity Staff and coordinates interface with external agencies and regulators in the member and provider appeals resolution process; maintains confidential files of all member and provider appeals and related activities
In the absence of the Senior Manager, oversees all CGA Unit staff and ensures that the CGA unit functions are efficiently and effectively managed.
Demonstrates proficiency with the principles and methodologies of process improvement. Applies these in the execution of responsibilities in support of a process focused approach.
Performs other duties as necessary or assigned
New York State Registered Nurse or equivalent clinical training
Bachelor's Degree in related field or equivalent knowledge
Minimum three years related experience with previous supervisory experience preferred. Previous experience managing member/provider appeals processes required
Knowledge of HMO/DOH regulatory guidelines and/or risk management background a plus
Proficiency in software applications that include, but are not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPoint and Outlook
Ability to work with minimal guidance; seeks guidance on only the most complex tasks
Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action
Excellent verbal and written communication skills; ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others.
Advanced interpersonal (e.g., mediating, counseling, mentoring, influencing), negotiating and management skills required to manage critical internal and external relationships and activities that are diverse and complex. Ability to collaborate constructively with others within and outside the organization.
Ability to work resourcefully and creatively, to think independently, and to exercise sound judgment in a complex and dynamic environment.
Commitment to the corporate mission, vision, and values.
High level of integrity as demonstrated by a) appropriate treatment of confidential information, b) adherence to policies, procedures, rules and regulations, c) professional conduct in dealing with persons internal and external to the organization, and d) sensitivity to the populations served by Affinity and the providers with which Affinity works.