Manager, Appeals

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
 

The Manager, Appeals oversees the appeals team for Martin’s Point Health Care Medicare Advantage and TRICARE products with supervisory responsible for daily operations, inventory management, performance, and training of the Appeals Specialists.

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.

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