BASF

Manager, Healthcare Audit Appeals

BASF

full-time

Posted on:

Origin:  • 🇺🇸 United States • Florida

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Salary

💰 $90 - $115 per year

Job Level

SeniorLead

About the role

  • Directs on-time delivery of appeal determinations and other forms of appeal support services for our business.
  • Oversees appeal determinations, coordination of CMS discussion periods, facilitation of appeal packets and the assessment and formulation of strategies for escalated appeals.
  • Oversees all commercial appeals ensuring compliance with various client protocols, processes and timelines.
  • Collaborates with Medical Directors, Subject Matter Experts and Audit leadership to develop and document internal audit standards to align with individual audit concepts, claim types and client-specific policies.
  • Prepares reports and manages appeal activities for assigned clients, including the daily management of inventories to ensure adherence to all client and internal Service Level Agreements pertaining to Turn Around Times and Quality.
  • Applies in depth level of expertise in development of policies and procedures and workflows processes to conduct appeals, discussion periods, assess the level of engagement on escalated appeals, to ensure staff accurately identify processing, procedural, systemic and billing errors and practices leading to claims inaccuracies.
  • Manages team members performing appeal activities to identify trends, determine root cause of payment inaccuracies, monitor the quality of auditor findings and to recommend process and systems improvements.
  • Proactively identifies opportunities for process improvement, efficiency, resolving problems, preparing and completing action plans.
  • Manages and trains appeal staff.
  • Supports staff recruitment, develops appeals auditors and builds effective teams.
  • Supports subcontractor communication, oversight and reporting.
  • Establishes accountability for performance monitoring (productivity/quality), communicates job expectations, trends, documentation, and ensures timelines are met.
  • Supports strategy by conducting needs assessments, capacity planning, cost/benefit analyses, preparing staffing models, establishing productivity and quality standards.
  • Maintains professional and technical knowledge by tracking emerging trends in audit management; attending educational workshops; reviewing professional publications; establishing personal networks; benchmarking state-of-the-art practices; participating in professional societies.
  • Develops effective relationships with leaders in the organization and has a strong understanding of the business.
  • Applies in-depth understanding of the inter-relationships of the business and support units throughout the organization.
  • Accomplishes organizational goals by accepting ownership of requests; exploring opportunities to add value.
  • Participates in business initiatives and pro-actively advises and assists the business on initiatives.
  • Builds HCS value and credibility with internal and external clients and represents the organization in meetings with the client, provider organizations, contractors, subcontractors and vendors.
  • Uses excellent communication skills to influence a wide range of internal and external audiences.
  • Provides timely response to escalated inquiries from the client and providers.
  • Supports other departments in problem resolution as necessary.
  • Completes required reports and ad hoc requests for information.
  • Inspires trust and credibility- delivers on commitments, audit subject matter expert.
  • Facilitates meetings as necessary.
  • Performs other duties as assigned.

Requirements

  • Active Registered Nurse license required.
  • Bachelor’s degree preferred.
  • At least 10 years of experience with increasing responsibility directly relevant to the job.
  • 5 or more years of Medical Coding experience is required.
  • Leadership experience is required, minimally at the Supervisor level; manager level or above is preferred.
  • Strong preference for prior experience overseeing audit or appeal-related operations, including responsibility for inventory assignments, SLA management and communication of audit results.
  • Must be able to work in a diverse and fast paced environment.
  • Strong working knowledge of MS Office