Senior Appeals & Resolution Manager

Prominence Health; Reno (NV); On-site; USD 90,000 - 150,000; Full time

Benefits offered by this job

Loan Forgiveness Program

Generous Paid Time Off

Excellent Medical, Dental, Vision and

401(K) with company match

SoFi Student Loan Refinancing Program

Career development opportunities

Job summary

Prominence Health is seeking a Manager, Appeals to lead the Appeals Department and ensure timely, compliant adjudication across Commercial, Self-Funded (ASO), and Medicare Advantage lines. You will drive performance, audit readiness, and continuous improvement while partnering with Medical Directors, Claims, Compliance, and Legal.

Ideal candidates have 5+ years in healthcare payer leadership, strong analytical and communication skills, and a proven track record of improving outcomes and

Qualifications

• 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.

Responsibilities

• Oversee the operational oversight of the Appeals Department and ensure regulatory compliance across Commercial, Self-Funded, and Medicare Advantage lines.
• Drive performance management and continuous improvement of appeal adjudication.
• Collaborate with Medical Directors, Utilization Management, Claims Operations, Compliance, Quality Management, Provider Relations, Legal, and Customer Service to optimize processes.
• Lead strategies to improve appeal outcomes, audit readiness, and member/provider satisfaction.

Skills

Leadership

Regulatory compliance

CMS audits

Data analysis

Communication

Healthcare payer operations

Project management

Education

BS in Health Administration or related field

Tools

Microsoft Office Suite

Kronos

Visio

Contract management systems

Job description

Prominence Health is seeking a Manager, Appeals to lead the Appeals Department and ensure timely, compliant adjudication across Commercial, Self-Funded (ASO), and Medicare Advantage lines. You will drive performance, audit readiness, and continuous improvement while partnering with Medical Directors, Claims, Compliance, and Legal.

Ideal candidates have 5+ years in healthcare payer leadership, strong analytical and communication skills, and a proven track record of improving outcomes and