Manager, Member & Provider Appeals

Locations Showing 1 location Cleveland, OH 44144, USA Description A hybrid role requiring 4 days per week on‑site in our Brooklyn, Ohio office. Applicants must reside within a 50‑mile radius of the Brooklyn, Ohio office. Manages staff and end‑to‑end operations for member and provider appeals and claim review. Ensures compliance with government regulations, accreditation standards, performance guarantees, and internal policies and procedures. Leads the implementation of procedural and system enhancements to strengthen operational efficiency. Establishes performance metrics, drives accountability, and promotes consistency across multiple locations and departments performing policy and administrative functions. Oversees service‑quality studies and reporting, identifying opportunities to improve both service delivery and operational effectiveness. Collaborates across the organization to support corporate goals and align business processes enterprise‑wide. Responsibilities Manages the day‑to‑day operation of the Appeal & Claim Review, ensuring workflow and escalated issues are handled and resolved. Monitors the effectiveness of programs and procedures. Identifies operational inefficiencies and recommends improvements. Develops, tests, and implements system and process changes. Assists with coordinating and facilitating processes and initiatives. Analyzes root cause of appeals. Tracks and trends issues to identify opportunities for improvement. Proactively identifies risks. Leads and/or participates in cross‑functional teams and committees to ensure comprehensive and coordinated efforts to remediate issues and facilitate process improvements throughout the organization. Reviews production and quality data to ensure accuracy and consistent application of policies and procedures. Maintains strong subject matter expertise in state and federal regulations and contractual obligations governing appeals. Ensures operational compliance with regulatory requirements and company policies. Ensures accurate timely reporting to meet internal and external reporting requirements. Oversees staffing, performance management, while motivating and coaching staff to achieve regulatory compliance and meet internal qualitative and quantitative productivity guidelines. Monitors work inventory and staff productivity and adjusts assignment to ensure productivity and compliance standards are met. Participates/contributes in accreditation compliance efforts including reporting, quality improvement studies and site visits. Contributes responses regarding appeal process matters initiated through the Request for Proposal process. Responsible for data validation reporting and analysis and oversight for STAR measures. Ensures timely and accurate written communication to providers, members, and regulatory entities regarding review status. Partners with the provider community, participates in joint operating committees, and project workgroups. Collaborates with providers, members, and across the organization to ensure that members are getting the appropriate care at the most appropriate time. Performs other duties as assigned. Qualifications Education and Experience The position requires a graduate of a registered nursing program approved by the Ohio State Nursing Board. Bachelor’s degree preferred. 8 years of progressive experience in health plan operations, appeals, clinical review, or related fields, including a minimum of 3 years in leadership. Experience with member/provider complaint resolution, and health insurance regulatory compliance preferred. Clinical appeal and claim review experience preferred. Professional Certification(s) Registered Nurse (Ohio) required Technical Skills and Knowledge Strong working knowledge of state and federal appeals regulations. Comprehensive understanding of operational process flows, including process‑flow analysis and quality/process improvement methods. Comprehensive knowledge of medical terminology, claims adjudication, UM processes, and applicable coding (ICD‑10, CPT, HCPCS, revenue codes) and benefits interpretation. Intermediate to advanced Microsoft Office and health insurance operations systems skills. Ability to formulate quality improvement initiatives, policies and procedures and management and regulatory reports. Ability to lead for optimal effectiveness, facilitate change, and produce results. Benefits A Great Place to Work: We will provide the equipment you need for this role, including a laptop, monitors, keyboard, mouse and headset. Whether you are working remote or in the office, employees have access to on‑site fitness centers at many locations, or a gym membership reimbursement when there is no Medical Mutual facility available. Enjoy the use of weights, cardio machines, locker rooms, classes and more. On‑site cafeteria, serving hot breakfast and lunch, at the Brooklyn, OH headquarters. Discounts at many places in and around town, just for being a Medical Mutual team member. The opportunity to earn cash rewards for shopping with our customers. Excellent Benefits and Compensation: Employee bonus program. 401(k) with company match up to 4% and an additional company contribution. Health Savings Account with a company matching contribution. Excellent medical, dental, vision, life and disability insurance — insurance is what we do best, and we make affordable coverage for our team a priority. Access to an Employee Assistance Program, which includes professional counseling, personal and professional coaching, self‑help resources and assistance with work/life benefits. Company holidays and up to 16 PTO days during the first year of employment with options to carry over unused PTO time. After 120 days of service, parental leave for eligible employees who become parents through maternity, paternity or adoption. An Investment in You: Career development programs and classes. Mentoring and coaching to help you advance in your career. Tuition reimbursement up to $5,250 per year, the IRS maximum. Diverse, inclusive and welcoming culture with Business Resource Groups. We maintain a drug‑free workplace and perform pre‑employment substance abuse and nicotine testing. Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor. #J-18808-Ljbffr Superior Dental Care, Inc.