Senior Manager Complaints & Appeals - Community Health Choice
Harris Health System
Location: Houston, Texas
Type: Full Time
Internal Number: 157395
JOB SUMMARY: Senior Manager of Complaints and Appeals ensures the proper management of all provider and member complaints as they relate to Adverse Determinations. The Senior Manager ensures that all regulatory deadlines are met. The Senior Manager of Complaints and Appeals will also apprise the Director of Quality & Outcomes in Medical Affairs of trends in adverse determinations that are either provider specific or specific to severity or intensity of service delivery.
The Senior Manager also acts as the lead Manager/trainer for the appeals team in the Medical Affairs Department. In this capacity, s/he will be responsible for orientation and training of new hires in the department as well as training for new products and product updates.
The Senior Manager is responsible for Quality Assurance of medical decision making for the appeals that are processed in the Medical Affairs Department. Together with the Department?s management team the Senior Manager will develop and implement regular Inter-rater Reliability Reviews for clinical appeals staff to ensure consistent application of evidence-based guidelines, Policies, or other authorization criteria as adopted by the health plan. Similarly, the Manager will review appeal results of overturned adverse determinations to identify areas requiring individual or departmental education. MINIMUM QUALIFICATIONS:
1. Education/Specialized Training/Licensure: Registered Nurse, current Texas License 2. Work Experience (Years and Area): At least 1 year as RN in acute care setting. Additional 1 year experience in Quality Improvement and in managed care setting preferred. 3. Management Experience (Years and Area): At least 1 year 4. Equipment Operated: Computer with knowledge of Word, Excel, Access and Outlook
SPECIAL REQUIREMENTS: Strong written and verbal communication skills (heavy public speaking), writing/composing correspondence and reports.
OTHER SKILLS: Analytical, medical terms, research, statistical, P.C., MS Word, MS Excel, MS Access, Typing: 35 wpm.
The Harris Health System is a fully integrated healthcare system that cares for all residents of Harris County, Texas. We are the first accredited healthcare institution in Harris County to be designated by the National Committee for Quality Assurance as a Patient-Centered Medical Home, and are one of the largest systems in the country to achieve the quality standard. Our system includes 23 community health centers, five school-based clinics, a dental center and dialysis center, mobile health units, a rehabilitation and specialty hospital and two full-service hospitals.Ben Taub Hospital is a world renowned Level I Trauma Center with 586 licensed acute-care beds and provides a wide range of specialty care outpatient services. Lyndon B. Johnson Hospital is a 328 licensed bed acute-care hospital with a newly expanded Level III trauma center and a distinguished regional center for neonatal intensive care for high-risk deliveries.Harris Health is a teaching system for Baylor College of Medicine and The University of Texas Health Science Center at Houston (UTHealth). We train the next generation of healthcare providers on the latest medical procedures and technological breakthroughs.With... our fully integrated electronic medical records system, we offer patients the convenience and assurance that their medical history is accurate, safe and available when and where it is needed. Our Medical Home designation ensures that we offer a full range of preventive, specialty and acute care services for the entire family.