Manager, Appeals/Resolution

UHS•Reno, NV

About The Position

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.

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.
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.

Nice To Haves

Experience with CMS audits, regulatory oversight, and compliance activities preferred.

Responsibilities

Operational oversight, regulatory compliance, performance management, and continuous improvement of the health plan's Appeals Department.
Lead the administration of member and provider appeals across Commercial, Self-Funded (ASO), and Medicare Advantage lines of business.
Ensure timely, accurate, and compliant adjudication of all appeals in accordance with federal and state regulations, CMS requirements, contractual obligations, and organizational policies.
Develop and implement strategies to improve appeal outcomes, ensure audit readiness, achieve regulatory compliance, optimize operational efficiencies, and enhance member and provider satisfaction.
Collaborate with Medical Directors, Utilization Management, Claims Operations, Compliance, Quality Management, Provider Relations, Legal, and Customer Service departments.