Supervisor Appeals - Medicare

Company : Highmark Inc. Job Description : JOB SUMMARY 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. ESSENTIAL RESPONSIBILITIES Displays effective communication skills. Verbal and written communication with Director and Senior Management, pe