Manager, Clinical Appeals

Job Summary: The Manager, Clinical Appeals is responsible for the oversight of all clinical appeals activities ensuring consistency of services and achievement of compliance targets. Essential Functions: Assist in coordination and management of the clinical appeals process related to adverse benefit determinations Ensure the consistent application of criteria used during the clinical appeals process Oversee clinical appeals data and processes to maintain industry standards and practices including decisions within allowable timeframes Interact with providers and staff to manage benefits aligned with state-based regulations, NCQA and CareSource policies Review and revise workflows to maximize efficiencies Monitor productivity, turnaround time and volume trends Oversee CQI activities and ensure audits and staff feedback occur at regular intervals Regularly report all clinical appeals regulatory requirements Ensure compliance with and reporting of all regulatory requirements Maintain all clinical appeals reporting and trend data Analyze under and over utilization information for impact on member quality of care and outcomes and formulate recommendations based on data Analyze state hearing, non-formulary exception, external and Independent Review Entity outcome data and formulate recommendations based on findings Develop, maintain and update all departmental policies and procedures; ensure notices of adverse action are provided in accordance with required regulations Audit clinica