Healthcare Appeals Manager: Compliance, Strategy & Ops

Prominence-Health-Plan; Reno (NV); Presencial; USD 90.000 - 130.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Loan forgiveness

Generous PTO

Medical/Dental/Vision

401K with company match

Student loan refinancing

Career development

Descripción de la vacante

Prominence Health Plan in Reno, NV seeks a Manager, Appeals to oversee the Appeals Department within a value-based care organization. You will ensure timely, compliant adjudication across Commercial, Self-Funded, and Medicare Advantage lines, and drive continuous improvement in outcomes and audit readiness.

Lead cross-functional collaboration with Medical Directors, Compliance, Legal, and Claims Ops to optimize processes, report metrics, and develop training for staff.

Formación

• Minimum 5 years of progressive healthcare payer experience.
• Minimum 5 years of leadership experience managing appeals, grievances, utilization management, claims, or related operations.
• Experience with Medicare Advantage plans required.
• Experience with Commercial and Self-Funded health plan operations required.
• Experience with CMS audits, regulatory oversight, and compliance activities preferred.
• Knowledge of state and federal regulations as they pertain to health insurance.

Responsabilidades

• Oversee the Appeals Department operations to ensure timely, accurate adjudication.
• Develop strategies to improve appeal outcomes and audit readiness.
• Collaborate with Medical Directors, Compliance, Legal, and Claims Operations.
• Monitor performance metrics and drive continuous process improvements.
• Lead training initiatives for adult learners and staff development.

Conocimientos

Healthcare payer

Leadership

Regulatory knowledge

Data analysis

Communication

Educación

BS in health administration

MBA or MHA preferred

Herramientas

Microsoft Office

Kronos

Descripción del empleo

Prominence Health Plan in Reno, NV seeks a Manager, Appeals to oversee the Appeals Department within a value-based care organization. You will ensure timely, compliant adjudication across Commercial, Self-Funded, and Medicare Advantage lines, and drive continuous improvement in outcomes and audit readiness.

Lead cross-functional collaboration with Medical Directors, Compliance, Legal, and Claims Ops to optimize processes, report metrics, and develop training for staff.