Manager, Appeals/Resolution

Prominence-Health-Plan; Reno (NV); On-site; USD 90,000 - 130,000; Full time

Benefits offered by this job

Loan forgiveness

Generous PTO

Medical/Dental/Vision

401K with company match

Student loan refinancing

Career development

Job summary

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.

Qualifications

• 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.

Responsibilities

• 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.

Skills

Healthcare payer

Leadership

Regulatory knowledge

Data analysis

Communication

Education

BS in health administration

MBA or MHA preferred

Tools

Microsoft Office

Kronos

Job description

Responsibilities

Prominence Health is a value-based care organization bridging the gap between affiliated health systems and independent providers, building trust and collaboration between the two. Prominence Health creates value for populations and providers to strengthen integrated partnership, advance market opportunities, and improve outcomes for our patients and members. Founded in 1993, Prominence Health started as a health maintenance organization (HMO) and was acquired by a subsidiary of Universal Health Services, Inc. (UHS) in 2014. Prominence Health serves members, physicians, and health systems across Medicare, Medicare Advantage, Accountable Care Organizations, and commercial payer partnerships. Prominence Health is committed to transforming healthcare delivery by improving health outcomes while controlling costs and enhancing the patient experience.

Learn more at: https://prominence-health.com/

Job Summary:

The Manager, Appeals is responsible for the operational oversight, regulatory compliance, performance management, and continuous improvement of the health plan's Appeals Department. This role leads the administration of member and provider appeals across Commercial, Self-Funded (ASO), and Medicare Advantage lines of business, ensuring timely, accurate, and compliant adjudication of all appeals in accordance with federal and state regulations, CMS requirements, contractual obligations, and organizational policies.

The Manager develops and implements strategies to improve appeal outcomes, ensure audit readiness, achieve regulatory compliance, optimize operational efficiencies, and enhance member and provider satisfaction. This position collaborates closely with Medical Directors, Utilization Management, Claims Operations, Compliance, Quality Management, Provider Relations, Legal, and Customer Service departments.

Benefit Highlights:

• Loan Forgiveness Program
• Challenging and rewarding work environment
• Competitive Compensation & Generous Paid Time Off
• Excellent Medical, Dental, Vision and Prescription Drug Plans
• 401(K) with company match and discounted stock plan
• SoFi Student Loan Refinancing Program
• Career development opportunities within UHS and its 300+ Subsidiaries! More information is available on our Benefits Guest Website: benefits.uhsguest.com

About Universal Health Services:

One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. During the year, UHS was again recognized as one of the World’s Most Admired Companies by Fortune; and listed in Forbes ranking of America’s Largest Public Companies. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located all over the U.S. States, Washington, D.C., Puerto Rico and the United Kingdom. www.uhs.com

Qualifications

Qualifications and Requirements:

• Minimum 5 years of progressive healthcare payer experience.
• Minimum 5 years of leadership experience managing appeals, grievances, utilization management, claims, or related healthcare operations.
• Experience supporting Medicare Advantage plans required.
• Experience with Commercial and Self-Funded health plan operations required.
• Experience with CMS audits, regulatory oversight, and compliance activities preferred.
• BS business administration, health administration, management, or equivalent experience.
• Knowledge of State and Federal regulations as they pertain to the health insurance industry.
• Experience with STAR ratings, care cap reports and risk scores
• Knowledge of CMS, NCQA, and HEDIS regulations as they pertain to the health insurance industry
• Proven experience reviewing and analyzing statistical data to identify trends as well as potential problems/opportunities for improved service quality.
• Versed in processes improvement techniques to reduce waste, and achieve efficiencies through simplifying complex processes within the department
• Ability to develop, use, interpret and apply key business metrics required
• Ability to organize and lead key initiatives required
• Knowledgeable of developing and implementing training for adult learners
• Strong written and verbal communication with an ability to effectively communicate with all types/levels of audiences required
• Experienced presentation skills and versed in public speaking
• Detail oriented; analytical ability; strong problem-solving skills required
• Advanced proficiency with all Microsoft Office Suite (Excel, Word, Visio, Outlook), and budgetary, time and attendance (Kronos) software systems.
• Resourceful and innovative in overcoming challenges through adapting, and responding quickly to change to gain efficiencies and increase productivity
• Must be able to make independent decisions, multi-task, prioritize tasks, and work with other internal departments to meet company goals.

All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates.

UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws.

We believe that diversity and inclusion among our teammates is critical to our success.