Campus Pride Jobs

Appeals Team Lead

Remote - Philadelphia, PA

*Please Note: If interested in this position, please send resume to thomas.lepera@montgomerycountypa.gov Once received, a prescreen will be conducted. Detailed instructions for applying on the employer's website will be provided during the prescreen.*

Your career starts now. We are looking for the next generation of health care leaders.

At AmeriHealth Caritas, we are passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we would like to connect with you.

Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

Responsibilities:

Reporting to the Supervisor, Appeals & Grievances, the Team Lead, Appeals & Grievances' primary responsibility is supporting the appeals staff with technical and process related questions.  Secondarily, responsible for providing support to the Supervisor, Appeals & Grievances with inventory management and staffing assignments as required to support SLAs.

• Functions as a technical specialist for Appeals.
• Maintains a current working knowledge of Appeals processing rules, contractual guidelines, plan policies, and operational procedures.
• Resolves obstacles and provides directions to Coordinators and Intake staff regarding case status and completion.
• Monitors reports for Benchmark concerns/issues related to each SLA component.
• Assists with Panel Hearing meetings coordination, as needed.
• Assists in managing inventory and preparing daily reports.
• Assists in identifying key issues with projects and offers solutions.
• Creates and supports an environment that fosters teamwork, cooperation, respect, and diversity. 
• Provides technical and peer in-service training, including side-by-side training.
•  Assist Supervisor, Appeals & Grievances in assigning work to staff and attend meetings as directed by supervisor or manager.
• Develops and maintains working relationships with multiple functional areas in the Enterprise.
• Participate in the OLH Processing Rule Committee and all other documentation.
• Is a knowledgeable Subject Matter Expert of each LOB supported.
• Supports Area Management (Director, Manager, Supervisor) with reports, special processes, projects.
• Ensuring the standard (30 day) contract turnaround time requirements are consistently maintained; expedited turnaround time requirement is also maintained per contract requirements.
• Assist in addressing audits reports and quality review feedback. 

Education/ Experience:

• Associate's Degree or equivalent work-related experience.
• 2 years of proven team leader or supervisory experience in the MCO or Healthcare space.
• Minimum 4 years experience with appeals, assignment of claims, processing health and dental claims, etc.
• Must be technically proficient using MS Suite and specifically, Adobe.
• Flexible to working in a fast-paced environment.
• Required ability to collaboratively or independently; deliver high-quality work; demonstrate intellect, resourcefulness, curiosity, attention to detail, and strong communication skills.
• Demonstrated knowledge of the medical documentation review process *(e.g., compliance letters, medical necessity, provider certifications) *
• Professional work practice in Healthcare, Medicare, and Medicaid, highly preferred (e.g., front office).

Diversity, Equity, and Inclusion

At AmeriHealth Caritas, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.

We keep our associates happy so they can focus on keeping our members healthy.

Our Comprehensive Benefits Package

Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.