Manager - Appeals

Description & Requirements

Maximus is looking for a Payment Determinations Manager to support our FED No Surprises Act (NSA) project.

This position is responsible for managing the payment determination decision process for disputes in the Independent Dispute Resolution process between healthcare providers and insurance companies.

This position must be able to use a range of measurements to forecast, monitor, analyze, plan, and manage resources to achieve contractual service level agreements, while maintaining a high level of customer service.

The Payment Determinations Manager will be responsible for the daily operations of the payment determinations staff.

This role requires a deep understanding of the NSA, knowledge about healthcare service and items and strong critical thinking.

Essential Duties and Responsibilities:

- Manage assigned teams and staff.

- Develop, monitor, and use quality control procedures and audit criteria to ensure consistent application of contractual requirements and established policies and procedures.

- Frequent interaction with subordinate employees, customers, and/or functional peer group managers, normally involving matters between functional areas, other company divisions or units, or customers and the company.

- Provide guidance to subordinates within the latitude of established company policies.

- Recommend changes to policies and establish procedures that affect immediate organization(s).

- Perform other duties as assigned by management.

- Manage Payment Determination Decision Process: oversee the payment determination decision process.

Monitor performance objectives for eligibility staff.

- Review Disputes and Payment Determination Decisions: review disputes for eligibility as well as payment determinations and make decisions based on policy guidelines and regulations.

Provide payment determination guidance for escalated disputes.

- Compliance- ensure all payment determination decisions comply with relevant laws, regulations, and organizational policies.

Address quality concerns with the payment determination teams.

- Documentation- maintain accurate and detailed records of all disputes, decisions, and communications.

- Stakeholder Communication- Act as the primary point of contact for parties, providing clear and concise information regarding the status and outcome of the payment determination review.

- Team Leadership- manage and provide guidance to the payment determinations team, ensuring high standards of performance and professional development.

Coach teams, set expectations, conduct performance evaluations, and support career development for assigned staff.

Identify and resolve employee issues, problems, and concerns.

- Continuous Improvement- identify areas for process improvement and implement changes to enhance the efficiency and effectiveness of the eligibility process.

- Reporting- prepare regular reports on eligibility outcomes, trends, and performance metrics for management.

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