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, 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 provid