Manager, Appeals and Grievances

Your Future Evolves Here

Evolent partners with health plans and providers to achieve better outcomes for people with most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of fragmented health care system and ensure people get the same level of care and compassion we would want for our loved ones.

Evolent employees enjoy work/life balance, the flexibility to suit their work to their lives, and autonomy they need to get things done. We believe that people do their best work when they're supported to live their best lives, and when they feel welcome to bring their whole selves to work. That's one reason why diversity and inclusion are core to our business.

Join Evolent for the mission. Stay for the culture.

What You’ll Be Doing:

The Appeals & Grievances Team offers candidates the opportunity to make a meaningful impact as part of a highly trained dedicated team focusing on Appeals and Grievances submitted by both members and providers. We maintain the principles of utilization management by adhering to Evolent and Client policies and procedures while complying with timeliness guidelines. Our team values collaboration, continuous learning, and a customer-centric approach, ensuring that every team member contributes to providing better health outcomes for the clients and members we serve.

Collaboration Opportunities:

• Internal teams: Utilization Management, Claims, Customer Service, Letter Writing, Market Operations, and more.
• External clients in meetings and to provide their metrics in a meaningful way. We also collaborate with providers as needed.

What You’ll Be Doing:

• Effectively manage a team to ensure a positive team environment:
  • Overseeing daily workflow.
  • Assess workloads and adjust as necessary to ensure work is completed timely and in compliance.
  • Conduct performance reviews to provide feedback and development opportunities.
  • Select, train and orient new team members

• Monitor productivity of Appeals and Grievance (A&G) coordinators to achieve timely, accurate and thorough resolution of A&G cases, while meeting performance standards and compliance requirements.
• Perform internal audits and monitor consistency and quality of the team to measure compliance with regulatory and accreditation standards. Participates in external audits, including document preparation and participation in on-site or remote audits, as a subject matter expert.
• Strict adherence to turn-around times with high-quality documentation in accordance with regulatory standards.
• Ability to multitask and respond quickly and accurately to issues and concerns for members and internal departments.
• Compile client reporting and presentation metrics for CCOM and other scheduled meetings, including deep dive into missed metrics and trends.
• Other duties as assigned by the Director, Appeals & Grievances.

• 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.

The Experience You Need (Required):

• 3+ years of appeals and grievances experience in a payer-based environment
• 3+ years of supervisory experience
• Expertise in Medicaid/Commercial appeals and grievances regulatory requirements
• Proficiency with PC-based software programs including Word, Excel and Outlook
• Excellent written and oral communication skills
• Ability to work remotely and independently

Finishing Touches (Preferred):

• Experience with fully insured and self-funded LOB including Exchange and ERISA requirements
• Experienced with CMS and other audits, preferably presenting cases to CMS and other entities
• Current working knowledge of Utilization Management
• Medical or claims coding experience
• Medical claims review experience
• Experience with or knowledge of claims processing practices
• Strong critical thinking, analytical, research and organizational skills
• Knowledge of NCQA and URAC accreditation
• Knowledge of CMS (Medicare/Medicaid) regulations and requirements
• Knowledge of Managed Care contracts/guidelines
• Working knowledge of various reimbursement mechanisms, including third party requirements

Technical Requirements:

We require that all employees have the following technical capability at their home: High speed internet over 10 Mbps and, specifically for all call center employees, the ability to plug in directly to the home internet