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, peers, departmental staff, and various Corporate support departments
- Verbal and written communication with external business partners including Program Safeguard Contractors (PSC), Recovery Audit Contractors (RAC), and Qualified Independent Contractors (QIC) and vendors
- Verbal and written communication with our customers including the Centers for Medicare and Medicaid Services (CMS), providers, and beneficiaries.
- Contribute to the achievement of the department performance standards specified in the Statement of Work, budget, CMS internet only manual, award fee, EIP or other program memoranda.
- Delegate work assignments to sustain department performance.
- Assist with budget preparation and monitoring.
- Monitor inventory levels and move resources, schedule cross training, etc… to effectively manage to CMS thresholds.
- Ensure compliance with management controls, process quality plans, change requests, internal and external audits, etc.
- Document department protocols and controls.
- Identify opportunities, through the use of Medicare policies and procedures, claims processing procedures and related data processing systems, to improve the Organization's Medicare Services overall performance.
- Assist in guideline and procedural development in accordance with CMS instructions.
- Utilize available technology to effectively monitor all departmental inventories.
- Provide direct oversight and/or technical direction as necessary of processing staff that make decisions to pay or deny services.
- Coordinate provider education activities.
- Maintain primary responsibility for all personnel related matters.
- Hire staff for the unit.
- Complete and conduct performance appraisals.
- Monitor individual performance and document according to HMS and Organization protocols .
- Provide frequent feedback to staff and taking corrective action when necessary.
- Sustain appropriate production and quality levels for all staff.
- Assure all staff provide a high level of quality service and professionalism .
- Ensure all appropriate refresher/remedial training as well as coaching/mentoring is conducted based on input from the Technical Assistants, Business Coordinators, and Monitoring and Inspection management feedback as appropriate.
- Provide feedback to management on the status of their section to ensure the section contributes toward the department meeting and exceeding all performance standards.
- Manage high profile or irate provider situations.
- Coordinate responses with other operational units or business partners as necessary.
- Coordinate activities and exchange of information with external business partners.
- Detect, investigate, research and analyze problems in the Medicare claims processing system and departmental procedures which contribute to the occurrence of appeal workload.
- Identify and analyze operating deficiencies and work with other Medicare personnel to develop the appropriate solutions.
- Recommend, coordinate and initiate improvements to the process to achieve efficiency, cost reduction, productivity, and quality gains.
- Assist or direct projects for achieving specified goals related to assignments and responsibilities of priority defined by the Organization's Medicare Services management.
- Provide support and recommendations to the Manager of the unit and may be designated to participate in decision-making, impacting the efficiency and performance of the overall operation of the department.
- Other duties as assigned or requested.
QUALIFICATIONS
Minimum
- High School diploma or GED
- 1-3 years of experience in a leadership/supervisory position
Preferred
- Medicare Program or Medicare regulations experience
- Appeals experience
- Experience using claims process system (e.g. MCS/FISS)
- Bachelor’s degree and 3 years of experience in a healthcare industry
- Associates degree and 5 years of experience in a healthcare industry
Skills
- 1-3 years of experience working in Medicare Program or with Medicare regulations
- 3-5 years of experience working on a personal computer in Microsoft Windows or similar environment
- Experience using claims process system (e.g. MCS/FISS)
- This position is subject to the general review by the Manager, Appeals. The incumbent is typically free to establish daily priorities with broad pre-established limits in order to effectively meet the assigned accountabilities. Results are monitored periodically
- Behavioral Skills: Strong verbal and written communication skills are required to effectively represent the position of the Organization's Medicare Services to various outside entities and internal staff
- Ability to multi task under pressure is an essential requirement
- Tact, diplomacy, and communication skills are essential skills
- Observe all applicable laws, regulations, company and divisional policies and procedures
- Approach business decisions with sound personal and professional ethics to reflect the Organization’s core values, Code of Business Conduct and the Integrity process
- Foster a reprisal free environment to promote open and constructive communication
- Demonstrate support of all ethics and compliance initiatives such as participation in the Integrity Process or compliance training and to consistently demonstrate support of the Organization’s core values, Code of Business Conduct and the Integrity Process through management decisions.
- Shares responsibility for quality with every member of the Organization. As part of this responsibility, the incumbent is accountable for identifying quality-related problems and notifying management when they believe quality is being compromised
- Expected to recommend process improvements designed to improve accuracy, timeliness of processing, and/or eliminate manual effort required
- •Must meet all CMS and Organizational Medicare Services security requirements
SCOPE OF RESPONSIBILITY
Does this role supervise/manage other employees?
Yes, number of direct reports: 30
WORK ENVIRONMENT
Is Travel Required?
No
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.
Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Pay Range Minimum:
$62,700.00
Pay Range Maximum:
$97,200.00
Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.
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