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PacificSource Health Plans · 1 month ago

Appeals Clinical Team Lead

Portland, OR

Full-time

Onsite

Senior Level

5+ years exp

PacificSource Health Plans is seeking an Appeals Clinical Team Lead to manage the appeals clinical staff and ensure effective operations. The role involves overseeing team performance, providing training and support, and collaborating with other departments to improve processes and service delivery.

CommunitiesCustomer ServiceNon Profit

Responsibilities

Take a leadership role in the development, implementation, and ongoing operation and maintenance of assigned programs, services, or functions

Improve the performance of the department through effective oversight and coaching of team members, managing team performance and improving processes and outcomes. Monitor daily workflow and caseloads and other work processes of team to assure appropriate distribution and processing of tasks

Responsible for the orientation and training of new hires

Provide ongoing supervision, training, evaluation, and leadership to assigned team members. This may include annual reviews, involvement in promotions and/or terminations of employees

Participate in hiring decisions in concert with Appeals and Grievance Director and HR

Monitor and evaluate team assignments relating to volumes, timelines, accuracy, customer service, and other quality and performance measures, and take actions as appropriate

Assist with process improvement and work with other departments to improve interdepartmental processes. Utilize LEAN methodologies for continuous improvement. Monitor key performance indicators and identify improvement opportunities

Serve as liaison with other PacificSource departments or community partners to coordinate optimal provision of service and information. Serve on various internal and external committees as required or designated. Document and report any pertinent communications back to the team or department

Utilize and promote use of evidence-based medical criteria

Maintain modified caseload consistent with assigned responsibilities

Facilitate investigation and resolution of process-related issues as needed. Facilitate conflict resolution, including interfacing with affected departments and individuals, as appropriate

Oversee and assist in providing exceptional service and information to members, providers, employers, agents, and other external and internal customers

Provide backup to other departmental teams or management staff, as needed

Meet department and company performance and attendance expectations

Relate new or revised policies, procedures and/or processes to team members to ensure they have the most up‐to‐date and current information

Facilitate team operations by discussions through the sharing of information and knowledge, identification of teamwork issues, development of problem‐solving recommendations, and recommendations of standardizing Health Services operations

Represent the Appeals and Grievance Department, both internally and externally, as requested by Appeals and Grievance Manager and/or Director

Perform other duties as assigned

Qualification

Registered NurseUtilization ManagementGrievanceAppealHealth Plan ExperienceAnalytical SkillsLeadershipCommunication SkillsOrganizational SkillsCollaborationCritical Thinking

Required

A minimum of five years clinical experience required

Registered Nurse/Licensed Social Worker with current appropriate unrestricted state license

Within 6 months of hire licensure may need to include Oregon, Montana, Idaho, Washington and/or other states as needed

Knowledge of health insurance and state mandated benefits

Thorough knowledge and understanding of medical procedures, diagnoses, care modalities, procedure codes (including ICD-10, HCPC CPT codes)

Effective adult education/teaching and/or group leadership skills

Ability to deal effectively with people who have various health issues and concerns

Strong analytical and organizational skills with experience in using information systems and computer applications

Flexible to meet the departments changing needs

Ability to develop, review, and evaluate utilization and case management reports

Good computer skills including experience with Word, Excel, and PowerPoint

Ability to use audio-visual equipment

Ability to work independently with minimal supervision

Preferred

Minimum of three years direct health plan experience in the following areas: utilization management, grievance and appeal, or claims review strongly preferred

Prior supervisory experience preferred