Weekend Appeals & Grievances Inventory Lead

Healthfirst; Pennsylvania; On-site; USD 89,000 - 132,000; Full time

Job summary

Healthfirst is seeking an Appeals & Grievances Weekend Inventory Manager to oversee weekend appeal operations and staffing. This full-time role requires coordinating with leaders to maintain compliant, high-quality output during Fri-Mon or Thurs-Sun shifts.

The ideal candidate has relevant healthcare or appeals experience, strong communication skills, and the ability to manage multiple priorities in a fast-paced environment while safeguarding HIPAA compliance.

Qualifications

• High school diploma or GED required.
• Experience in appeals and grievances or healthcare environment.
• Strong verbal and written communication skills.
• Ability to work independently in a fast-paced environment with multiple priorities.
• Weekend availability (Fri-Mon or Thurs-Sun).
• Experience with care management systems such as CCMS, TruCare and Hyland.

Responsibilities

• Prepare and plan the weekend staff's assignments and volume to ensure compliance.
• Triage and assign expedited appeals while helping standardize and optimize how Appeals and Grievances are routed.
• Manage inventory to ensure regulatory compliance for appeals processed through the weekend.
• Communicate and elevate cases to Medical Peer reviewers.
• Maintain delegated vendor relationships and ensure vendor performance and compliance measures are met.
• Coordinate with outside departments for case escalation, clarifications and collaboration needed for appeal resolution.
• Manage letter review and printing and coordinate with the mailroom for expedited printing needs.
• Review case change requests and cancellations including appropriate routing for follow up.
• Review and submit Level 2 appeals packets to the appropriate entity.
• Maintain knowledge of industry trends, best practices and protocols and share with other units comprising the enterprise to ensure general consistencies and enhancements.
• Identify trends and recommend solutions for improvement.
• Maintain best practices and strategically deploy approaches to meet production, compliance and quality targets to perform all Appeals & Grievances tasks.
• Build partnerships with business areas across and outside of operations to improve communication and responsiveness to multiple conflicting resource demands.
• Provide feedback and recommendations to leadership concerning staff performance.
• Comply with HIPAA guidelines and maintain confidentiality of member, provider, medical and departmental information.
• Adhere to state and federal compliance and regulatory guidelines.
• Additional duties as assigned.

Skills

Verbal communication

Written communication

Independent worker

Time management

Weekend availability

Education

High school diploma or GED

Bachelor's degree

Tools

Microsoft Word

Excel

Macess

CCMS

TruCare

Hyland

Job description

Healthfirst is seeking an Appeals & Grievances Weekend Inventory Manager to oversee weekend appeal operations and staffing. This full-time role requires coordinating with leaders to maintain compliant, high-quality output during Fri-Mon or Thurs-Sun shifts.

The ideal candidate has relevant healthcare or appeals experience, strong communication skills, and the ability to manage multiple priorities in a fast-paced environment while safeguarding HIPAA compliance.