Company Statement
Connecticare is a leading health plan in the state of Connecticut and a subsidiary of EmblemHealth, a health and wellness company that provides insurance plans, primary and specialty care, and wellness solutions. WellSpark is a digital wellness company and national subsidiary of EmblemHealth that offers a full suite of products and solutions to reward people for healthy behaviors.
Supervisor, Grievance & Appeals -Clinical
🔍 New York, New York
Summary of Position
Direct supervision of the Clinical Nurse Reviewer staff, oversee the clinical team and operational functions related to the review of clinical records and service appeals for purposes of providing clinical summaries on clinical appeals.
Responsibilities:
• Under the direction of the director, is responsible for the execution of efficient departmental processes designed to oversee the medical review process for clinical appeals and par provider retrospective utilization reviews, ensuring all cases sent for medical review meet regulatory and departmental timeframes. Evaluates the medical review process and recommends process improvements.
• Responsible for the supervision of the clinical staff, ensuring the timely and appropriate execution of day-to-day inventory and quality management.
• Performs ongoing analysis to make recommendations to the department director regarding volume, case type, etc. Make recommendations to the department director regarding corrective action and/or counseling as needed, in addition to developing processes and procedures that improve the quality and processing of clinical reviews.
• Create visibility and support for payment review programs for internal and external customers. Collaborate with interdepartmental leaders to resolve issues and improve processes and workflows.
• Organizes after-hour and weekend coverage, as required.
• Coach and mentor to staff.
• Ensures compliance with State, Federal and NCQA requirements related to utilization management activities.
• Under the direction of the Director; trains, evaluates and develops assigned staff.
• Develops, monitors, and communicates performance expectations and plans for all direct reports and conducts performance reviews within specified timeframe. Provides feedback on a regular basis. Assists with resolution of employee performance issues.
• Maintains an environment of quality improvement through continuous evaluation of processes and policies. Identifies and recommends new technologies and process efficiencies.
• Interacts with various departments throughout the organization and contributes to the resolution of interdepartmental issues. Leads and develops team to quickly assess and diagnose root causes to problem areas.
• Actively participates on assigned committees and projects.
• Performs duties of a clinical reviewer as needed
• Performs other duties as assigned.
Qualifications:
• Bachelor’s Degree in Nursing preferred, health care, or business, or an equivalent combination of education and experience
• LPN/RN
• Active unrestricted license or certification required.
• At least 4-6 years of clinical experience required
• At least 2 years of managed care experience preferred
• Supervisory experience preferred
• State of the art knowledge of care management tactics
• Strong oral and written communication and interpersonal skills
• Strong organizational skills
• Strong knowledge of Microsoft Office products including Word, Excel, and Access
Security Disclosure
If you are offered a job from one of the EmblemHealth family of companies that includes ConnectiCare, AdvantageCare Physicians, and WellSpark, the offer confirmation email will come from “HRTalentAcquisition” with the subject line: “Offer of Employment for (job title)” – Please respond online”.
We never ask you to join a Google Hangout, request you to purchase your own equipment or pay to apply. We do not send email from a third-party email service such as Yahoo or Gmail.
Pay Disclosure
A good faith estimate of the compensation range for individuals hired to work for the EmblemHealth Family of Companies is provided. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate’s work experience, education/training, internal peer equity, and market and business considerations. The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. It is not typical for an individual to be hired at or near the top of the range, as compensation decisions depend on each case’s facts and circumstances. Union roles covered by a collective bargaining agreement will compensate in accordance with the union contract.
EEOC Statement
We are committed to leveraging the diverse backgrounds, perspectives, and experiences of our workforce to create opportunities for our people and our business. We are an equal opportunity/affirmative action employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex/gender, sexual orientation, gender identity or expression, pregnancy or related condition, marital status, national origin, disability, protected veteran status or any other characteristic protected by law.