[Hiring] Supervisor Appeals @Highmark Health

Role Description

This job supervises the Part A and/or Part B Medicare Fee-for-Service appeals unit within the Organization's Medicare Services. Delegates assignments to appeal representatives and technical staff. Manages resources to ensure CMS thresholds and internal customer standards are achieved, in all workloads, within the unit (re-determinations, telephone and written re-openings, effectuations, and Provider Monitoring). The incumbent assists with budget preparation and monitoring of performance towards budget. Ensures compliance with all corporate standards as well as all CMS requirements as they relate to change requests, management controls, process quality plans, internal and external audits, etc. The incumbent is responsible for the direct oversight and/or technical direction of non-clinical staff that make determinations to pay or deny services, identify provider education opportunities, and appropriate referrals to other contractors (Program Safeguard Contractor (PSC) for potential fraud and abuse activities, Qualified Independent Contractor (QIC) for second level appeals, etc…). Communicates with/educate external entities including the Centers for Medicare and Medicaid Services, Office of Inspector General, appellants and their authorized representatives, etc. on appeal related issues.

Qualifications

• Minimum: High School diploma or GED
• 1-3 years of experience in a leadership/supervisory position
• Preferred: Bachelor’s degree and 3 years of experience in a healthcare industry
• Associates degree and 5 years of experience in a healthcare industry
• 1-3 years of experience working in Medicare Program or with Medicare regulations
• 3-5 years of experience working on a personal computer in Microsoft Windows or similar environment
• Experience using claims process system (e.g. MCS/FISS)

Requirements

• Strong verbal and written communication skills are required to effectively represent the position of the Organization's Medicare Services to various outside entities and internal staff
• Ability to multi-task under pressure is an essential requirement
• Tact, diplomacy, and communication skills are essential skills
• Observe all applicable laws, regulations, company and divisional policies and procedures
• Approach business decisions with sound personal and professional ethics to reflect the Organization’s core values, Code of Business Conduct and the Integrity process
• Foster a reprisal-free environment to promote open and constructive communication
• Demonstrate support of all ethics and compliance initiatives such as participation in the Integrity Process or compliance training
• Shares responsibility for quality with every member of the Organization
• Must meet all CMS and Organizational Medicare Services security requirements

Benefits

• Pay Range Minimum: $62,700.00
• Pay Range Maximum: $97,200.00
• Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations.