Appeals Manager Resume Sample
King Braun
239 Keeling Canyon,
Houston,
TX
+1 (555) 823 0594
Work Experience
Appeals Manager
12/2015
-
PRESENT
Philadelphia, PA
- Monitor & report associate benchmarks and performance monthly to provide incentive or perform disciplinary action as required
- Evaluates new processes and makes recommendation for change
- Supervise staff; conduct performance reviews, sets unit standards, and scorecard goals
- Manage the data gathering and analysis of reports regarding appeal and complaint activity as well as preparation for appeals audits. Provide employee training, monitor QI activities of appeals department, and assist in the development of department workflows and implementations
- Respond to member, provider, and client inquiries regarding status, process and outcome of appeals. Consult with clinical managers on problem cases and interface with case managers, clinical supervisors, account managers and other Magellan employees in resolving denial and appeal questions
- Collaboration with Highmark’s Provider Network
- Knowledge of CMS regulatory guidelines (i.e. Chapters 13 and 18). Works with Compliance / Regulatory Affairs and Legal teams that support the Government business units for interpretation of guidelines to resolve member appeal issues
Manager of Denials & Appeals
06/2012
-
08/2015
Los Angeles, CA
- Excellent written, verbal, and presentation skills required. Ability to interact with all levels of personnel, along with knowledge of principles and practices of effective supervision
- Effective decision-making abilities, strong communication, and organizational skills
- Prioritize time and resources, as well as ability to identify staff needs
- Complaint resolution and negotiation skills required
- Working knowledge and training in effective customer service techniques. Active listening and observation skills required. Proven ability to provide outstanding customer service
- Manage levels of performance and assist with employees’ professional growth by planning and building an effective organization; communicating effectively; coordinating with others; maintaining employee morale; motivating, recognizing and rewarding others; coaching and developing others; managing performance and engaging in self-development
- Leadership experience within the healthcare industry with knowledge of health insurance plans, terminology, benefits, claims processing, and enrollment and billing
Manager Appeals
02/2008
-
04/2012
San Francisco, CA
- Experience in Operations to include inventory management, engaging and resolving complex and sensitive customer issues or office management experience
- Strong Communications Skills used primarily for verbal and written responses to CMS, BEIC, several internal business partners modeling and coaching others
- Experience presenting complex materials, to include legal documents, to individuals outside the company such as regulatory agencies, external audit staff, court officials and/or court appointed mediators
- Experienced user of MS Word, Excel, PowerPoint to capture action plans, reports and present data to audiences at all levels of the organization
- Maintains strong subject matter expertise in Medicare Advantage and Part D rules and requirements. Ensures compliance with regulatory requirements and company policies. Monitors changes to regulatory guidance to support revisions to department workflows, systems, training, desk procedures and policies. Ensures accurate and timely regulatory reporting and internal management reporting
- Provides day to day supervision of operations and staff to meet performance expectations and regulatory requirements. Manages employee performance while motivating and coaching staff to achieve compliance and positively influence STARS ratings. Promotes professional development
- Provides support and direction to the call center(s) supporting Medicare Advantage, especially as it relates to training, desk procedures, new strategic initiatives, regulatory changes and general performance improvements to support compliance and STARS
- Participates in accreditation site visits and audits including preparing materials for review
- Progressive health plan operations experience, primarily in Medicare, 3 years in a leadership capacity
Education
American Sentinel University
2003 - 2008
Bachelor's Degree in Health Informatics
Professional Skills
- Strong critical thinking, analytical, research and organizational skills
- Superior organization and analytic skills, including strong applied knowledge of Excel
- Skills in time management (e.g., planning, organizing, directing, controlling, etc.)
- Skills in oral and written communication including public speaking
- Evidence of analytic problem-solving skills
- Skills in leadership in the development and implementation of administrative, technical and physical safeguards to protect the privacy of health information
- Experience and demonstrated ability to read and understand complex documents; Required
How to write Appeals Manager Resume
Appeals Manager role is responsible for training, research, editing, sharepoint, excel, finance, mainframe, litigation, reporting, modeling.
To write great resume for appeals manager job, your resume must include:
- Your contact information
- Work experience
- Education
- Skill listing
Contact Information For Appeals Manager Resume
The section contact information is important in your appeals manager resume. The recruiter has to be able to contact you ASAP if they like to offer you the job. This is why you need to provide your:
- First and last name
- Telephone number
Work Experience in Your Appeals Manager Resume
The section work experience is an essential part of your appeals manager resume. It’s the one thing the recruiter really cares about and pays the most attention to.
This section, however, is not just a list of your previous appeals manager responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular appeals manager position you're applying to.
The work experience section should be the detailed summary of your latest 3 or 4 positions.
Representative Appeals Manager resume experience can include:
- Strong working knowledge of Medicare Advantage and Part D regulations and operations
- Strong understanding of benefit operations functional areas that have an upstream / downstream impact
- Strong knowledge of claims and customer service operations policies, procedures, and systems
- Understanding of operational process flow analysis and process improvement methods
- Maintaining the responses within the turnaround time requirements
- Provide expertise or general appeals support to teams in reviewing, researching, investigating, negotiating, processing and completing cases
Education on an Appeals Manager Resume
Make sure to make education a priority on your appeals manager resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your appeals manager experience. For example, if you have a Ph.D in Neuroscience and a Master's in the same sphere, just list your Ph.D. Besides the doctorate, Master’s degrees go next, followed by Bachelor’s and finally, Associate’s degree.
Additional details to include:
- School you graduated from
- Major/ minor
- Year of graduation
- Location of school
These are the four additional pieces of information you should mention when listing your education on your resume.
Professional Skills in Appeals Manager Resume
When listing skills on your appeals manager resume, remember always to be honest about your level of ability. Include the Skills section after experience.
Present the most important skills in your resume, there's a list of typical appeals manager skills:
- Manage daily activities related to our Shared service Clinical Appeals function, ensuring processes are performed efficiently and effectively
- Strong preference for experience in customer service or member or patient complaints or regulatory compliance investigations
- Support staff and department with resolving appropriate procedural issues that affect maintaining effective operations
- Experience managing relationships with clients and / or vendors
- Experienced with CMS and other audits, preferably presenting cases to CMS and other entities
- Experience working with managed and non-managed health care benefits; Required
List of Typical Experience For an Appeals Manager Resume
1
Experience For Manager of Denials & Appeals Resume
- Managing cross functional teams on large scale projects
- Manage recruitment and hiring of staff
- Adapt to and be an agent of positive change in a developing work environment
- Proficiency in software application including but not limited to MS Office
- Monitors all appeal processing to assure compliance for all State and Federal regulatory requirements and accreditation standards
- Makes and approves recommendations for personnel regarding employment, performance ratings, salary changes, promotions, transfers and terminations
- Participates in the budgetary process for the department and monitoring of adherence
- Knowledge of appeal handling and clinical protocols
2
Experience For Manager, Medicare Advantage Appeals Resume
- Work with software systems for data capture of appeals and reporting of findings
- Knowledge of accreditation requirements related to appeal processing
- Monitor appeals and provide senior management with weekly reporting on trends
- Review and Process incoming incident/accident reports
- Consult with Legal Counsel, Physician Reviewers, Medical Directors, and Project Directors as necessary
- Develop, monitor, and use quality control procedures and audit criteria to ensure consistent application of contractual requirements and established policies and procedures
3
Experience For Manager Appeals Resume
- Experience with DME required
- Maintain an effective Member Medical Necessity, Administrative and Provider Appeals Program for commercial members
- Maintains updated knowledge of Client requirements
- Five years’ work in team-based operations
- Demonstration of year-over-year improved efficiency and innovation
- Perform comfortably in a fast-paced, deadline-oriented production environment
- Collaborates closely with Care Management to ensure proactive inter-departmental communication and process symmetry
- Maintain continuous interface with regionally based clinical services Departments in order to provide collaboration with program development
- Monitors and directs staff performance to assure that Department and regulatory goals are continually maintained, including those related to maximizing service to members
4
Experience For NV MCD Manager, Grievance & Appeals Resume
- Acts as a resource to staff and other departments concerning benefits clarification, medical policy, provider and quality related complaints and other quality related issues
- Development of effective operational links to Medical Directors and internal and external consultants for all levels of appeals
- Develops and maintains a working relationship with the legal department as an integral part of interpretation and application of all regulatory requirements and accreditation standards and risk management
- Knowledge of Medical, clinical services Precertification, Claims Payment Policies, and all relevant Federal, state-specific mandates and standards established by accrediting organizations to serve as a resource for staff. Creation and revision of Appeal Policy and Overviews as needed
- Develop and maintain a positive working relationship with internal departments and external entities to assure compliance, improve member satisfaction and accomplish departmental goals
- Appeals experience
- Demonstrated ability to manage processes and staff
5
Experience For Manager, Denials & Appeals Resume
- Provide report on effectiveness of fraud rules based on data gathered from appeals process
- Direct appeals/grievance experience in Medicare or Medicaid; Required
- Upervisory experience; Required
- Appeals and grievances experience in a payer-based environment
- Any equivalent experience/education
- Medical claims review experience
6
Experience For Grievance & Appeals Manager Resume
- Oversight of all incoming and outgoing correspondence and communication to members/providers and consultants
- Oversight of creation, revision and implementation of all manuals and letters for the appeals department as well as interaction with other departments for the creation and maintenance of initial denial letters
- Oversight of all Departmental Record Retention and archiving
- Participates in all committees and workgroups related to appeal processing, letter automation, tracking data entry and collection, benefit language, HIPAA requirements and Record Retention
- Work under time pressures, complete reports and work across departments to meet deadlines for customer deliverables
- Ensure that the appeals department process all appeals and grievances in accordance with referred time frames and other contractual legal requirements
7
Experience For Manager, Appeals & Grievances Resume
- Create framework to automate appeals workflow
- Work with various external constituencies related to grievance and appeals
- Recommend solutions and works with department and company staff to ensure problems are advised of corrective measures to prevent recurrences
- Experience as a Grievance and Appeal Analyst, or 3 years’ experience as a; Sr. Grievance and Appeal Analyst, Grievance and Appeal Consultant, Grievance or Appeal Supervisor/Manager
- Proficiency with PC-based software programs including Word, Excel and Outlook
8
Experience For Manager, Medicare Appeals & Grievances Resume
- Expertise in Medicare Part C appeals and grievances regulatory requirements
- Access to high speed broadband or DSL internet in a secure home office
- Travel to client, vendors and other Evolent locations, approximately 20-35%
- Knowledge of contracts management
- In tech industry
List of Typical Skills For an Appeals Manager Resume
1
Skills For Manager of Denials & Appeals Resume
- Experience with managing process improvement and quality assurance
- Experience in dealing with Medicare products and services
- Experience leading large production based teams
- Experience in claims, claims customer service or appeals/grievance in a healthcare setting
- Supervisory experience required in a managed care environment
- Upervisory / managerial experience in claims adjudication, appeals or customer service
- Experience in a management position
2
Skills For Manager, Medicare Advantage Appeals Resume
- Coordinate the Client component of the State Hearing, Independent Medical Review (IMR), and/or DMHC appeal processes
- Leading large production based teams
- Other requirements (licenses, certifications, specialized training, physical abilities needed to perform the job)
- Knowledge of grievance, appeal and fair hearing rules and regulations outlined in the Balanced Budget Act of 1997
- Knowledge of acute health care policies and practices, including claim adjudication, fraud and abuse, ethics, service delivery and contract compliance
3
Skills For Manager Appeals Resume
- Assist teams when necessary in coordination of case processing and workload adjustment
- Grievance & Appeals: knowledge of Medicare Managed Care guidelines and State regulations of G&A processes
- Review retrospective authorization requests/claims documentation within specified timeframes
- Serve as primary liaison with other departments to resolve complex grievance issues
- Maintain accurate and complete appeals/grievance records in the database
- Participate in audits and prepare responses to audit findings and/or corrective action as needed
- Conduct regular audits of Grievance and Appeals Coordinators’ work, analyze results, coordinate the collection of deliverables, and execute corrective action plans (CAP) to address any identified issues
4
Skills For NV MCD Manager, Grievance & Appeals Resume
- Analyze new or updated regulations, laws and contract language and implement appropriate changes to internal policies, procedures and workflows
- An active registered nurse (RN) license
- Strong organizational and time management skills, attention to detail and problem-solving, good written and verbal communication skills, ability to work independently without direct supervision
- Five (5+) years’ home health experience
- Three (3+) years’ management experience
5
Skills For Manager, Denials & Appeals Resume
- Provide guidance to a team of 4-10 Frontline Supervisors who manage the day-to-day operational activities for their teams
- Intermediate PC skills (Word/Excel- editing and creating) and keyboarding skills with previous experience navigating multiple SharePoint Sites, as well as internal systems to retrieve data
- Demonstrated ability to build strong relationships across all levels of an organization
- Business office experience in the assigned area
- Intermediate PC skills (Word / Excel - editing and creating) and keyboarding skills with previous experience navigating multiple SharePoint Sites, as well as internal systems to retrieve data
6
Skills For Grievance & Appeals Manager Resume
- Operations leadership experience with direct or indirect reports is required
- Demonstrated success in a fast-paced, results-oriented environment
- Knowledge of management practices and procedures
- Provide sound interpretation of the federal Health Insurance Portability and Accountability Act (HIPAA) that directly impacts the maintenance of health information
- Analyze, interpret and understand how insurance rates are developed for acute care and long term care services
- Independent Adjuster (Accident & Health) license or the ability to acquire within 90 days of employment
- Experience using a computer and Microsoft Office including Microsoft Word (create correspondence and work within templates), Microsoft Excel (data entry, sort / filter, and work within tables), and Microsoft Outlook (email and calendar management
- Write policies, procedures, forms, templates and other documents that are compliant with Federal laws
- Conduct quality improvement initiatives and lead large cross-functional teams
7
Skills For Manager, Appeals & Grievances Resume
- Reviews all rules, regulations, laws, legal opinions, etc., and analyzes impact on Division operations
- Reviews and approves all proposed resolutions of service delivery claim disputes, grievances and appeals (member, client parent, acute care and long-term care providers) before they are forwarded to the Assistant Director
- Reviews and approves requests and communications with the Attorney General's Office for claim disputes, grievances, appeals, fair hearings, litigation settlements, subpoenas, summons, requests for records, and informal and formal legal opinions
- Designs and develops the process used for providers, members, families, advocates, stakeholders regarding claims disputes, grievances, appeals, fair hearings, and also develops programs and procedures to monitor and review all acute care and long-term care programs
- Provides technical assistance to acute care/long-term care providers and Division staff regarding claim disputes, grievances, appeals, fair hearings, and related federal and state regulations, rules, policies and procedures
8
Skills For Manager, Medicare Appeals & Grievances Resume
- Represents the Division and testifies as an expert witness regarding state and federal rules, policies and procedures at fair hearings
- Designs and develops management and operations analysis systems and methods for all Division programs and activities
- Oversee and manage daily operations and the direct the functions of the grievance coordination and research in provider disputes
- File preparation, maintenance and set-up
- Verbal, electronic, and written communication with practitioners and/or members
- Data entry into the appropriate information system
- Manage daily operations and the processing of all Provider 2nd Level Disputes and state complaints, ensuring their completion in a manner which meets all mandated requirements
- Oversees the recruitment, interviewing, and hiring of permanent staff
- Implements education strategies targeted at member orientation, retention, wellness, HEDIS measures, and to reduce member grievances and appeals
9
Skills For Manager Denials & Appeals Resume
- Works with Director and project teams to ensure that all projects meet stated financial, operational and timeline goals
- Maintain familiarity and compliance with federal, state and local regulations as well as other regulatory requirements (e.g. NCQA standards) relative to appeal and grievance operations
- Review report on trends related to appeals & grievances
- Coordinates continuous benefit education to current members; provides changes and updates to membership on a regular basis
- Conduct documentation audits to ensure to adherence to quality assurance standards for quality documentation
- Maintain line of business responsibility for state member eligibility inquiries and act as liaison between member services and state enrollment business owners (including on-site state eligibility staff)
- Manage teams ensuring they follow MAXIMUS policies and procedures
10
Skills For Manager of Appeals & Grievances Resume
- Authorize the appropriate payment or refers cases to investigators for further review
- Administer performance management processes to include developing and implementing training plans, monitoring quality and productivity, administering corrective/disciplinary action when necessary, and administering the performance evaluation process
- Act as liaison for the management team with other shared services functions, including Production Services, Training, Performance Management, and Business Intelligence as necessary
- Supervisory or training experience
- Experience with fully insured and self-funded LOB including Exchange and ERISA requirements
- Medical or claims coding experience
- Experience with or knowledge of claims processing practices
- Experience working with Quality Assurance
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