Sr Manager-Clinical Appeals

American Specialty Health Incorporated is seeking a Senior Manager; Clinical Appeals to join our Clinical Quality Administration (CQA) department. This position will perform clinical appeals review and make decisions; support other staff who are doing similar work; talk with practitioners as necessary to address questions or decisions; and support ad-hoc initiatives, including Fraud, Waste, and Abuse prevention and related activities within the organization.

Remote Worker Considerations

Candidates who are selected for this position will be trained remotely and must be able to work from home (WFH) in a designated work area with company-provided technology equipment. This remote/WFH position requires you have a stable connection to your Internet Service Provider with the ability to participate by video in online meetings over a reliable and consistent network (minimum internet download of 50 Mbps and 10 Mbps upload speed).  

Responsibilities

• Appeals review and sign off in collaboration with each of the Clinical Services teams that make medical necessity decisions.
• Serves on ASH Quality Improvement Committee (voting member.)
• Makes medical necessity decisions on appeal cases in coordination with Clinical Quality Evaluation staff and leadership. Assists in process and systems development support for the appeals management process. Works with Subject Matter Experts (SMEs) and Medical Directors to complete case review tasks. Reviews chiropractic, acupuncture, physical and occupation therapy, speech language pathology appeals, obtaining input and sign off by applicable SMEs.
• Support guideline review and development including support to the Evidence Evaluation Committees.
• Supports Clinical Policy review, Clinical Performance System, and High Performing Provider programs.
• Effectively communicates rationale for clinical decision making to peers using evidence/outcomes-based principles and professional experience.
• Document all telephonic communications, via phone log/ASHCore system, detailing all pertinent facts and resolutions to issues discussed with practitioners.
• Coordinate outreach for Cigna Assist and Anthem Assist requests, prepare clinical summaries of reviewed appeals upon client request.
• Create clinical summaries and outreach for Department of Insurance Complaints (DOI) and Health plan Medical Director investigations.
• Manage the accuracy and confidentiality of quality-related communications.
• Assist staff, as appropriate, in supporting the resolution of quality-of-care issues.
• Attend meetings with customers when requested by department leadership.
• Support process efficiency through support of system-based technology (e.g., automation of routine transactional functions).
• Provides ad hoc SME support to Chief Health Services Officer and other Senior leadership as requested.
• Manages projects in support of department goals.
• Serves as resource to directors, managers, and staff relating to compliance and/or procedural inquiries.

Qualifications

• A licensed health care practitioner from an accredited health care college or university in one of the licensed health care specialties managed by ASH (DC, PT, OT, ST, LAc, ND, DPM) or a physician (MD or DO) and a current, unrestricted license to practice the applicable health care specialty in the State of California and ability to get additional licenses as necessary.
• Advanced training, certification, or on-the-job experience in health care administration; clinical case review and/or Quality Administration.
• Minimum 5 years of clinical experience.
• Specific experience to include medical necessity review and clinical appeals review (required).
• Minimum 8 years health care administration. Specific experience to Health Quality Improvement (HQI) program implementation, including specialty health care operations, regulatory compliance, coordination of policy development, support of practitioner-based committees and experience in Quality Improvement (QI) data analysis preferred.
• Experience working within a Health Plan other than ASH (preferred.)
• Use of computer in health care application required.
• Knowledge of ASH Systems and Programs (preferred.)
• Credentials meet ASHG credentialing criteria.
• Health Plan clinical decision making.
• Demonstrated writing abilities.

Core Competencies

• Demonstrated ability to interact in a positive, respectful manner and establish and maintain cooperative working relationships.
• Ability to display excellent customer service to meet the needs and expectations of both internal and external customers.
• Excellent listening and interpersonal communication skills to identify critical core competencies based on success factors and organizational environment.
• Ability to effectively organize, prioritize, multi-task and manage time.
• Demonstrated accuracy and productivity in a changing environment with constant interruptions.
• Demonstrated ability to analyze information, problems, issues, situations, and procedures to develop effective solutions.
• Ability to exercise strict confidentiality in all matters.

Mobility

Primarily sedentary, able to sit for long periods of time.

Physical Requirements

Ability to speak, see and hear other personnel and/or objects. Ability to communicate both in verbal and written form. Ability to travel within the facility. Capable of using a telephone and computer keyboard. Ability to lift up to 10 lbs. Ability to travel within and outside State of California by car and/or airplane as required.

Environmental Conditions

Work-from-home (WFH) environment.

American Specialty Health is an Equal Opportunity/Affirmative Action Employer.

All qualified applicants will receive consideration for employment without regard to sex (including pregnancy, childbirth, related medical conditions, breastfeeding, and reproductive health decision-making), gender, gender identity, gender expression, race, color, religion (including religious dress and grooming practices), creed, national origin, citizenship, ancestry, physical or mental disability, legally-protected medical condition, marital status, age, sexual orientation, genetic information, military or veteran status, political affiliation, or any other basis protected by applicable local, federal or state law.

Please view Equal Employment Opportunity Posters provided by OFCCP here.

If you are a qualified individual with a disability or a disabled veteran, you have the right to request an accommodation if you are unable or limited in your ability to use or access our career center as a result of your disability. To request an accommodation, contact our Human Resources Department at (800) 848-3555 x6702.

ASH will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the Company’s legal duty to furnish information.

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