Manager um clinical appeals and grievancesGenfinity

It's Time For A Change...Your Future Evolves Here
Evolent Health has a bold mission to change the health of the nation by changing the way health care is delivered. Our pursuit of this mission is the driving force that brings us to work each day. We believe in embracing new ideas, challenging ourselves and failing forward. We respect and celebrate individual talents and team wins. We have fun while working hard and Evolenteers often make a difference in everything from scrubs to jeans.
Are we growing? Absolutely and Globally. In 2021 we grew our teams by almost 50% and continue to grow even more in 2022. Are we recognized as a company you are supported by for your career and growth, and a great place to work? Definitely. Evolent Health International (Pune, India) has been certified as "Great Places to Work" in 2021. In 2020 and 2021 Evolent in the U.S. was both named Best Company for Women to Advance list by Parity.org and earned a perfect score on the Human Rights Campaign (HRC) Foundation's Corporate Equality Index (CEI). This index is the nation's foremost benchmarking survey and report measuring corporate policies and practices related to LGBTQ+ workplace equality.
We recognize employees that live our values, give back to our communities each year, and are champions for bringing our whole selves to work each day. If you're looking for a place where your work can be personally and professionally rewarding, don't just join a company with a mission. Join a mission with a company behind it.
Manager UM Clinical Appeals and Grievances
Position Summary
The Manager, UM - Appeals and Grievances oversees the company's appeals and grievances process and ensures appeals and grievances are processed in accordance with federal and state laws and regulations, contract provisions, accreditation standards, and internal policies and procedures. The Manager, UM - Appeals and Grievances serves as a liaison between members and providers regarding grievances, complaints, and appeals related to denials of medical services, membership and benefits issues, reimbursements, and quality of service. The Manager, UM - Appeals and Grievances is responsible for the presentation of appeals to the Medical Director, Center for Medicare and Medicaid Services, contracted reviewer, Client, and/or the contracted external review agency in accordance with applicable laws, organizational policies, and regulatory requirements. The Manager, UM - Appeals and Grievances must be able to conduct thorough research, detailed documentation, and corrective action planning for each case and complete all components of the case review within the time frames as outlined in federal and state statutes, rules, and regulations, contract provisions, accreditation standards, and internal policies.
Roles & Responsibilities
Accountable and report into Director or Senior Director, Appeals and Grievances
Effectively manage a clinical and non-clinical team members to ensure a positive team environment, conduct performance reviews to provide feedback and development opportunities
Using subject matter expertise, prepare and deliver reports reflecting open cases, cases approaching timeliness, cases requiring escalation, closed case reporting, client reporting and other reports to manage the appeals and grievances function. Reports may be delivered to internal and/or external stakeholders
Select, train and orient new team members
Monitor productivity of Appeals and Grievance (A&G) team to achieve timely, accurate and thorough resolution of A&G cases, while meeting performance standards and compliance requirements
Perform audits and monitor consistency and quality of the team to measure compliance with regulatory and accreditation standards
Oversee daily workflow, assess workloads and adjust as necessary to ensure work is completed timely and in compliance
Administers Standard and Expedited Appeals Processes in compliance with applicable federal and state regulatory requirements, contracts, and national accreditation standards.
Strict adherence to turn-around times with high-quality documentation in accordance with regulatory standards is required
Ability to interpret and operationalize multiple regulatory requirements and differences in each.
Ability to multitask and respond quickly and accurately to issues and concerns for members and internal departments.
Participates in audits, including document preparation and participation in on-site or remote audits, as a subject matter expert.
Abides by HIPAA regulations and confidentiality requirements; document, research and review member grievances, involving quality of care or quality of service with appropriate clinical and/or other department staff.
Collaborates with appropriate staff to resolve member and provider complaints or grievances; formulate improvement measures and responses; prepare written correspondence to member and others as required.
Educates and monitors compliance with grievance and appeal procedures in such departments as the contact center, claims, and medical management.
Compile client reporting and reporting for JOC and UMC, that will show TAT, type of appeal and grievances, volumes and to provide oversight of upstream and downstream processes impacting grievances and appeals.
Participates in meetings where discussion on platform system buildout and config are discussed to ensure regulatory and client requirements are captured.
Communicate and partner with other Evolent Health departments, clients, vendors and stakeholders
Other duties as assigned
Qualifications
An active and unrestricted Nursing License in the Philippines and in the mainland US
At least 5-year experience in US healthcare with at least 2 years in a supervisory/managerial position
Minimum of two-year experience of Utilization Management in a managed care setting
Strong clinical knowledge
Expertise in Medicaid/Medicare appeals and grievances regulatory requirements, experience with CMS audits and presentations is an advantage
Proficiency with PC-based software programs including Word, Excel and Outlook
Excellent written and oral communication skills
Experience with fully insured and self-funded LOB including Exchange and ERISA requirements
Working knowledge with medical claims cycle/processing including coding, review and reimbursement is preferred
Strong critical thinking, analytical, research and organizational skills
Experience with NCQA and URAC accreditation is an advantage
Knowledge of CMS regulations /requirements and Managed Care guidelines is preferred
Strong written communication skills
Hours of Operation: US Business Hours
Compensation & Benefits
Earn more than ₱99,000 per month;
HMO coverage includes you and a dependent.
Evolent Health is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, or national origin.
Evolent Health intends to establish a great working environment in the Philippines and offers a competitive benefit package. Candidates offered a position must be able to successfully pass the background check. * Skills testing may be required. Employees will initially be hired by Genfinity with the expectation that they will be transferred to Evolent.
Genfinity

Makati City, Metro Manila
₱99,000 per month
Permanent
Full-time