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Manager of UM Appeals

Company: MetroPlus Health Plan
Location: New York
Posted on: November 26, 2022

Job Description:

Empower. Unite. Care.MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care. We believe that Health care is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.About NYC Health + HospitalsMetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth's network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.Position OverviewThe Manager of UM Appeals reports to the Director of UM Appeals and supervises the Care Management Associates (CMAs), which includes monitoring all UM Appeal intake and processing activities, assigning coverage, providing reports, and developing/reinforcing workflows and new programs. The Manager of UM Appeals is responsible for managing authorization-related issues from the claims department. This includes investigating and resolving Care Connect (CCONT) issues impacting the adjudication of claims. The Manager of UM Appeals conducts claims clean-up when needed and generates management reports to inform training and systems implementation. Job Description

  • Supervision and monitoring of the CMA's Appeals related activity to ensure responsiveness, accuracy, and compliance with regulatory requirements.
  • Ensures consistency in customer service including, coordinating and providing back-up coverage. Flag issues for corrective action and provide reinforcements to the CMAs of new programs and workflows.
  • Create, maintain, and review daily, weekly, and monthly appeal related reports of the CMA's activities including productivity metrics.
  • Investigate and resolve problematic authorizations identified by Claims department. Resolving claims issues and generating management reports to evaluate training needs and systems implementation.
  • Managing the appeals intake process, including but not limited to ensuring appropriate triaging of mail, accurate scanning and filing of records, appropriate CCONT data entry and case set up, generation of appropriate letters, timely member and provider notification, and overall compliance with regulatory requirement.
  • Serve as an additional resource to the UM Appeals Unit with regards to TXEN/PowerStepp and CCONT issues.
  • Investigate, document, follow-up and resolve any issues that negatively impact performance of the unit. Escalates appropriately when issues are outside of scope of responsibilities.
  • Actively participate in training of CMAs with regards to reinforcement of established workflows and changes resulting from regulatory updates and/or quality improvement initiatives.
  • Monitors performance of CMAs and prepare action plans to develop competencies of new and existing CMAs.
  • Participate in pre-screening, interview, and recruitment of new Utilization Appeal CMA team members.
  • Responsible for coordinating work schedule to ensure daily coverage, including tracking review of all time and leave requests.
  • Responsible for effective developmental coaching and counseling to employees, both verbal and written. Initiate disciplinary steps when necessary, including tracking and preparation of counseling, warning, disciplinary requests in accordance with Group 12 and managerial policy.
  • Prepare the annual performance reviews for CMAs and Claims Coordinator. Meet with employees to review and provide with necessary feedback.
  • Responsible for review and weekly submission of employee timesheets.
  • Perform other duties as assigned by the Director of UM Appeals.Minimum Qualifications
    • Associate Degree and a minimum of 2 years of UM experience; or
    • An equivalent combination of education, training, and experience
    • One year of supervisory experience required
    • 2 years of satisfactory full-time experience working with PowerStepp/TXEN Claims screens or comparable system
    • Excellent data entry skills; able to learn, use, and toggle between multiple systems
    • Analytical skills and ability to create reports, charts and graphs (e.g. Microsoft Excel)
    • Understanding of medical terminology and knowledge of CPT-4 and ICD-9 codes preferred
    • Prior supervisory experience strongly preferredProfessional Competencies
      • Integrity and Trust
      • Customer Focus
      • Functional/Technical Skills
      • Written/Oral Communications

Keywords: MetroPlus Health Plan, New York , Manager of UM Appeals, Executive , New York, New York

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