Manager - Appeals

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.

- Oversees the day-to-day operations of the Appeals department.
- Ensures appeals are reviewed and resolved in a timely manner.

- Maintains accuracy and consistency in appeal determinations.

- Ensures compliance with regulatory, contractual, and company requirements.

- Monitors team performance, productivity, and workload distribution.

- Performs Monthly Quality Checks.

- Provides monthly and as-needed coaching, guidance, and performance feedback to team members.

- Oversees compliance with policies, procedures, and regulatory guidelines.

- Identifies and implements process improvement opportunities.

- Drives operational efficiency and workflow optimization.

- Analyzes trends and performance metrics to improve outcomes.

- Collaborates with management to address escalated issues.

- Supports a positive customer experience through fair and effective appeal resolution.

- Promotes continuous improvement initiatives to enhance service quality and customer satisfaction.

Minimum Requirements

- Bachelor's degree in relevant field of study and 5+ years of relevant professional experience required, or equivalent combination of education and experience.
- Familiarity with Appeals & Hearings is required.

Expertise within the Hearings & Appeals function is strongly preferred.

- Current and/or prior managerial experience.

- Ability to work a schedule between the hours of 9:00am - 6:00pm EST Monday - Friday.

- Flexibility to work extended hours and rotational weekends.

Preferred Skills and Qualifications:

- Knowledge of and experience with healthcare appeals.

- Quality check, review, and/or assessment experience.

- Experience working with Salesforce.

- Familiarity with the Affordable Care Act.

Please note: For this position Maximus will provide equipment to use.

Home Office Requirements:

- Internet speed of 25mbps or higher required / 50 Mpbs for shared internet connectivity (you can test this by going to www.speedtest.net)

- Minimum 5mpbs upload speed

- Connectivity to the internet via Category 5 or 6 ethernet patch cable to the home router

- Private and secure work area and adequate power source

- Must currently and permanently reside in the Continental US

- Must have a smartphone which will be required to log into Maximus systems

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