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Northwell Health Supervisor, Appeal Resolution in Melville, New York

Req Number 27409

Job Description

Job Description

Supervises and oversees the operations of the centralized appeals and denial prevention process for the organization. Performs quality audits on clinical reviews and appeal letters. Facilitates the even work-flow to maintain timely response to clinical review and appeals.

Job Responsibility

  • Promotes Appeal Resolution department goals by selecting, motivating, and training capable team members.

  • Leads the activities of assigned Appeal Resolution team members by communicating and providing guidance toward achieving department objectives.

  • Supervises, hires, trains, disciplines, and evaluates the performance of staff; ensures performance appraisals on inpatient auditors are completed in a timely manner.

  • Provides training to new employees; performs monthly quality reviews on staff; identifies, evaluates, and implements opportunities for efficiencies.

  • Plans, organizes, coordinates, and evaluates staffing requirements to meet operational goals; assigns and schedules direct reports to ensure smooth and efficient workflow.

  • Promotes staff development and education by providing opportunities for formal and informal education to promote competency; develops and performs staff educational programs; ensures staff completes annual training.

  • Maintains data tracking systems and provides reports to staff; sets performance standards and provides ongoing feedback to staff.

  • Generates department metrics; reports operational performance, justification, and/or corrective action.

  • Oversees and coordinates appeals process.

  • Reviews and evaluates cases denied by all Third Party payers and determines follow through for level of appeals; assigns cases to staff, as appropriate.

  • Monitors inpatient denials and assists patients and physicians with management of the appeals process.

  • Performs related duties as required. All responsibilities noted here are considered essential functions of the job under the Americans with Disabilities Act. Duties not mentioned here, but considered related are not essential functions.

Job Qualification

  • Graduate from an accredited School of Nursing required.

  • Current License to practice as a Registered Professional Nurse in New York State required, plus specialized certifications as needed.

  • 4-6 years of relevant experience and 0-2 years of leadership / management experience, required.

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