What are the responsibilities and job description for the Manager, Appeals position at Martin's Point Health Care?
Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015.
Position Summary
Job Description
Key Outcomes:
- Ensures Appeal Specialists research, process and resolve all appeals in accordance with TRICARE and NCQA guidelines, or CMS guidelines as applicable to the member’s specific plan.;
- Prioritize Appeals Specialist team members across multiple streams of work utilizing Martin’s Point Management System principles when appropriate.
- Collaborate with health plan leaders and front-line staff to inform process improvement both upstream and downstream of appeals.
- Serve as the primary lead for internal and external appeals related audit and accreditation activities.
- Create, develop and/or maintain a high performing team.
- Create, maintain, and revise appeals policies, procedures, standard work, and training materials to reflect current CMS and / or Tricare manuals, and NCQA accreditation standards, as required.
- Establish and maintain calendar and workplan for quality control monitoring programs, internal and external audits and accreditation activities.
- Performs analysis of appeals volumes, causes, and performance results and disseminate to respective compliance committees, regulatory bodies, and / or health plan leadership, as applicable.
- Perform the core functions of the Appeals Specialist role as needed to meet contractual and regulatory requirements.
- Prepare staffing analysis and budget activities to ensure efficient operations.
- Represent the appeals function at committees, workgroups, and strategic projects.
Education/Experience:
- Bachelor’s Degree or equivalent experience and education required.
- 5 years’ experience in managed care plans including experience in a leadership role.
- Demonstrable experience leading a Medicare Advantage and/or TRICARE appeals team required.
- Deep knowledge of Medicare Advantage and/or TRICARE appeals requirements and processes required.
- Experience in health plan operations and or compliance required.
- Prior experience with and participation in NCQA accreditation and / or CMS audit activities strongly preferred.
Skills/Knowledge/Competencies (Behaviors):
- Exceptional written and verbal communication skills.
- Demonstrate understanding and modeling of Martin’s Point values.
- Self-driven and self-motivated with a demonstrable track record of producing high-quality work.
- Strong interpersonal skills and the ability to collaborate with internal and external clients.
- Excellent customer services skills.
- Strong analytical, research, and problem-solving skills.
- Proficiency in Microsoft Office applications (Word, Excel, PowerPoint).
- Strong organizational skills and able to meet deadlines (ability to prioritize while maintaining focus on objectives).
- Takes appropriate initiative while soliciting input/advice appropriately.
- Ability to handle confidential and sensitive information in a discreet and professional manner.
We are an equal opportunity/affirmative action employer.
Do you have a question about careers at Martin’s Point Health Care? Contact us at:
jobinquiries@martinspoint.org
