• Job Description

  Req#: 34435

  Your career starts now. We are looking for the next generation of healthcare leaders.

  At AmeriHealth Caritas, we are passionate about helping people get care, stay well, and build healthy communities. As one of the nation's leaders in healthcare solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services, and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together, we can build healthier communities. We would like to hear from you if you want to make a difference.

  Headquartered in Newtown Square, Pennsylvania, AmeriHealth Caritas is a mission-driven organization with over 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

  Discover more about us at: https://www.amerihealthcaritas.com/careers/index.aspx

  Responsibilities:

  Under the direction of the Manager, Appeals & Grievances, the Supervisor will oversee the appeal intake and grievance processes, ensuring compliance with all State and other mandated guidelines. Inform appropriate staff of company policy, initiative requirements, and recommendations and ensure proper implementation. Coordinate with other departments, such as clinical, account executives, and member services staff, regarding appeal and grievance-related activities. Produce statutory reports related to appeals and grievances. The incumbent is also accountable for the following:

  • Manage daily operations and the processing of all grievances and the intake for appeals, ensuring their completion in a manner that meets all mandated requirements
  • Supervise the Appeals & Grievances Coordinator and Clinical Appeals Reviewers
  • Maintain familiarity and compliance with federal, state, and local regulations and other regulatory requirements (e.g., NCQA standards) relative to appeal and grievance operations
  • Review reports on trends related to appeals and grievances
  • Support staff and departments with resolving appropriate procedural issues affecting effective operations
  • Provide training to departments, State, and consumer representatives
  • Conduct documentation audits to ensure adherence to quality assurance standards for quality documentation

  Education/Experience:

  • Bachelor’s Degree in Nursing required; RN preferred
  • Requires:
    • Minimum three (3) years of supervisory experience in appeals and grievances in the managed care space. Clinical background preferred.
    • Strong customer service background
    • Knowledgeable in assessing data percentages and performance management systems (e.g., Verint)
    • Proficiency in JIVA, FACETS and EMR, Microsoft Office Suite (Excel, PowerPoint, Adobe Pro, Outlook); InterQual is a plus
    • Must thrive in a fast-paced environment, exercise sound judgment, deliver high-quality work, demonstrate intellect, resourcefulness, curiosity, attention to detail, and strong communication skills
    • Must be solutions-driven with advanced written/verbal communication skills; handle varying workloads with high integrity, promptness, and accuracy.
    • Ability to sustain consistent service levels and meet deadlines
    • Tenacity to persevere, handle challenging deliverables, and uphold knowledge of the organization’s business processes
  • REMOTE; however, may require some travel to the office based on business need
    

  Diversity, Equity, and Inclusion

  At AmeriHealth Caritas, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that all associates have a fair opportunity to achieve their full potential. We implement these principles daily by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.

  We keep our associates happy so they can focus on keeping our members healthy.

  Our Comprehensive Benefits Package

  Flexible work solutions include remote options, hybrid work schedules, competitive pay, Paid Time Off (PTO), including holidays and volunteer events, health insurance coverage for you and your dependents on Day 1, 401(k), tuition reimbursement, and more.

• About the company

  AmeriHealth Caritas is a different kind of health care company. Our goal is to provide responsible managed care solutions, including Medicaid, Medicare, and CHIP — plus pharmacy benefit management, behavioral health, and administrative services.

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