| Appeals Nurse Supervisor Who We Are: TurningPoint Healthcare Solutions is a leader in advanced clinical and technology-enabled complex condition management. TurningPoint provides an innovative suite of specialty care management services and technologies that enable health plans and employers to improve the safety, quality, and affordability of healthcare. Through its platform and specialized team of clinical experts, TurningPoint works collaboratively with providers to deliver optimal care. TurningPoint offers condition-specific, quality-driven, value-based care management services that optimize care from diagnosis and discovery through recovery. TurningPoint’s comprehensive and integrated suite of services enhances the support individuals need, at the time they need it most. Since launching in 2015, TurningPoint has provided support to more than 50 million people nationwide across numerous clinical specialties including musculoskeletal, pain management, cardiology, wound care, ear/nose/throat, and sleep. TurningPoint’s model moves beyond denial-based care to holistic condition management that improves outcomes and reduces cost. TurningPoint is an independent organization, not owned or affiliated with a health plan or provider system. Position Summary: The UM Appeals Supervisor has responsibility over the quality and production, on-going training, and support as well as guidance of decision making for the identified teams. The UM appeals supervisor is expected to monitor productivity and turn-around time (TAT) of appeals and claims requests. The UM Supervisor will be responsible for the team adherence and reporting of metrics and KPI to the senior staff as well as interfacing with the client. The position will require the monitoring of and oversight of the audit process as well as decision making for medical necessity and quality of healthcare services for pre-authorization grievance and appeal requests, claim review requests, and claim appeal requests. Roles and Responsibilities: - Support the appeals and claim team and monitoring the daily work of the appeal team members to ensure accuracy in documentation and compliance with the associated UM policies and procedures.
- Review, research and resolve incoming inquiries from various entities, updating any information required in CRM/ the appropriate system.
- Monitor adherence and reporting of metrics and KPls to management as well as interfacing with the client, ensuring service and quality levels are met for all programs.
- Monitor the audit process for appeals and claim reviews as well as the decision making for medical necessity/ documented quality of healthcare services for pre-authorization grievance and appeal requests, claim review requests, and claim appeal requests.
- Serve as point of contact for questions, assistance and training to the appeals team.
- Identify and resolve operational problems using defined processes, expertise and judgement.
- Adhere to all compliance and quality management program requirements around the handling of complaints, grievances and other reportable events.
- Provide written and oral communication to management for cost savings, productivity gains and improvements in customer service.
- Provide coaching and counseling to appeals team members to ensure they are meeting expectations set forth in the communication and distribution of company policies, procedures and responsibilities that directly relates to the assigned contract/ client expectations.
- Manage time and attendance for salaried and non-salaried team members.
- Demonstrates understanding of client business requirements to ensure that their needs are being met.
- Assist with the hiring, development and evaluation of all staff, including handling corrective action when necessary
- Support Clinical Operations daily with working the phone queue whenever possible, especially during peak/ overflow periods, while also responding to any/ all escalated calls.
- Monitor productivity for the team to include adherence to contractual service level agreements (SLAs).
- Perform appeals and claims duties when unforeseen circumstances require action so to prevent a negative impact to performance.
- Serve and protect the company by adhering to URAC standards, professional standards, policies and procedures, federal, state, and local requirements, and professional and licensing standards.
- Participate in educational opportunities, read professional publications, maintain personal networks; participate in professional organizations.
- Enhance company reputation by accepting ownership for accomplishing new and different requests; exploring opportunities to add value to job accomplishments.
- Follow company policies and procedures and conducts annual performance reviews in a timely manner.
- Respect and maintain HIPAA confidentiality guidelines.
- Other duties as directed.
Education, Experience and Licensure: - Active and unrestricted Registered Nurse or License Practical Nurse licensure in any State in the United States.
- Diploma of nursing from an accredited school required.
- Bachelor's Degree in a health-related field preferred. Or equivalent years of experience.
- Minimum of 5 years of experience in healthcare operations with 2 years in Utilization Management preferred.
- Previous experience as a Team Lead / Leader of People preferred.
- Excellent verbal and written communication skills.
- Ability to foster a cohesive working environment.
- Must be experienced in medical terminology and have a strong attention to detail.
- High degree of accuracy in dealing with authorization issues is required.
- Strong communication, multi-tasking and interpersonal skills needed to lead a wide variety of personalities.
Preferred Skills: Creating a Safe, Effective Environment, Verbal Communication, Listening, Confidentiality, Dependability, Emotional Control, Teamwork. Strong organizational skills; commitment to customer service; ability to problem solve; strong presentation skills throughout all levels of the organization. Must be able to foster a positive and productive work environment with ability to lead, build teams and motivate staff. Proficient in Microsoft Word, Excel and Outlook. TurningPoint Healthcare Solutions is an Equal Opportunity Employer.
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