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Evolent Health Manager, Appeals and Grievances in Topeka, Kansas

It’s Time For A Change…

Your Future Evolves Here

Evolent Health has a bold mission to change the health of the nation by changing the way health care is delivered. Our pursuit of this mission is the driving force that brings us to work each day. We believe in embracing new ideas, challenging ourselves and failing forward. We respect and celebrate individual talents and team wins. We have fun while working hard and Evolenteers often make a difference in everything from scrubs to jeans.

Are we growing? Absolutely – about 40% in year-over-year revenue growth in 2018. Are we recognized? Definitely. We have been named one of “Becker’s 150 Great Places to Work in Healthcare” in 2016, 2017, 2018 and 2019, and one of the “50 Great Places to Work” in 2017 by Washingtonian. We recognize employees that live our values, give back to our communities each year, and are champions for bringing our whole selves to work each day. If you’re looking for a place where your work can be personally and professionally rewarding, don’t just join a company with a mission. Join a mission with a company behind it.

What You’ll Be Doing:

Your Future Evolves Here

Evolent Health has a bold mission to change the health of the nation by changing the way health care is delivered. Our pursuit of this mission is the driving force that brings us to work each day. We believe in embracing new ideas, challenging ourselves and failing forward. We respect and celebrate individual talents and team wins. We have fun while working hard and Evolenteers often make a difference in everything from scrubs to jeans.

Are we growing? Absolutely about 40% in year-over-year revenue growth in 2018. Are we recognized? Definitely. We have been named one of “Becker’s 150 Great Places to Work in Healthcare” in 2016, 2017, 2018 and 2019, and One of the “50 Great Places to Work” in 2017 by Washingtonian. We recognize employees that live our values, give back to our communities each year, and are champions for bringing our whole selves to work each day. If you’re looking for a place where your work can be personally and professionally rewarding, don’t just join a company with a mission. Join a mission with a company behind it.

What You’ll Be Doing:

Evolent Health is looking for a Manager, UM - Appeals and Grievances to lead the UM Appeals and Grievance team. The Manager, UM - Appeals and Grievances oversees the Evolent Health appeals and grievances process and ensures appeals and grievances are processed in accordance with federal and state laws and regulations, contract provisions, accreditation standards, and internal policies and procedures. The Manager, UM - Appeals and Grievances serves as a liaison between members and providers regarding grievances, complaints, and appeals related to denials of medical services, membership and benefits issues, reimbursements, and quality of service. The Manager, UM - Appeals and Grievances is responsible for the presentation of appeals to the Medical Director, Center for Medicare and Medicaid Services, contracted reviewer, Client, and/or the contracted external review agency in accordance with applicable laws, organizational policies, and regulatory requirements. The Manager, UM - Appeals and Grievances must be able to conduct thorough research, detailed documentation, and corrective action planning for each case and complete all components of the case review within the time frames as outlined in federal and state statutes, rules, and regulations, contract provisions, accreditation standards, and internal policies. The Appeals and Grievances reports to the Associate Director, Utilization Management.

What You’ll Be Doing:

  • Effectively manage a team to ensure a positive team environment, conduct performance reviews to provide feedback and development opportunities

  • Using subject matter expertise, prepare and deliver reports reflecting open cases, cases approaching timeliness, cases requiring escalation, closed case reporting, client reporting and other reports to manage the appeals and grievances function

  • Select, train and orient new team members

  • Monitor productivity of Appeals and Grievance (A&G) team to achieve timely, accurate and thorough resolution of A&G cases, while meeting performance standards and compliance requirements

  • Perform audits and monitor consistency and quality of the team to measure compliance with regulatory and accreditation standards

  • Oversee daily workflow, assess workloads and adjust as necessary to ensure work is completed timely and in compliance

  • Administers Standard and Expedited Appeals Processes in compliance with applicable federal and state regulatory requirements, contracts, and national accreditation standards.

  • Strict adherence to turn-around times with high-quality documentation in accordance with regulatory standards is required

  • Ability to interpret and operationalize multiple regulatory requirements and differences in each.

  • Ability to multitask and respond quickly and accurately to issues and concerns for members and internal departments.

  • Participates in audits, including document preparation and participation in on-site or remote audits, as a subject matter expert.

  • Abides by HIPAA regulations and confidentiality requirements; document, research and review member grievances, involving quality of care or quality of service with appropriate clinical and/or other department staff.

  • Collaborates with appropriate staff to resolve member and provider complaints or grievances; formulate improvement measures and responses; prepare written correspondence to member and others as required.

  • Educates and monitors compliance with grievance and appeal procedures in such departments as the contact center, claims, and medical management.

  • Compile client reporting and reporting for JOC and UMC, that will show TAT, type of appeal and grievances, volumes and to provide oversight of upstream and downstream processes impacting grievances and appeals.

  • Participates in meetings where discussion on platform system buildout and config are discussed to ensure regulatory and client requirements are captured.

  • Communicate and partner with other Evolent Health departments, clients, vendors and stakeholders

  • Other duties as assigned by the Associate Director, Utilization Management

The Experience You Need (Required):

  • 3+ years of appeals and grievances experience in a payer-based environment

  • 3+ years of supervisory experience

  • Expertise in Medicaid/Medicare appeals and grievances regulatory requirements

  • Proficiency with PC-based software programs including Word, Excel and Outlook

  • Access to high speed broadband or DSL internet in a secure home office

  • Excellent written and oral communication skills

  • Ability to travel to client, vendors and other Evolent locations, approximately 20-35%

  • Ability to work remotely and independently

Finishing Touches (Preferred):

  • Licensed Nurse RN) or equivalent clinical or medical work experience

  • Experience with fully insured and self-funded LOB including Exchange and ERISA requirements

  • Experienced with CMS and other audits, preferably presenting cases to CMS and other entities

  • Current working knowledge of Utilization Management

  • Medical or claims coding experience

  • Medical claims review experience

  • Experience with or knowledge of claims processing practices

  • Strong critical thinking, analytical, research and organizational skills

  • licensed practical/vocational nurse preferred

  • Three years’ experience in health care management and/or insurance

  • Knowledge of NCQA and URAC accreditation

  • Knowledge of CMS (Medicare/Medicaid) regulations and requirements

  • Knowledge of Managed Care contracts/guidelines

  • Working knowledge of various reimbursement mechanisms, including third party requirements

  • Knowledge of managed care principles, HMO and Risk Contracting arrangements

Evolent Health is an Equal Opportunity/Affirmative Action Employer

Technical requirements:

Currently, Evolent employees work remotely temporarily due to COVID-19. As such, we require that all employees have the following technical capability at their home: High speed internet over 10 MBPS and, specifically for all call center employees, the ability to plug in directly to the home internet router. These at-home technical requirements are subject to change with any scheduled re-opening of our office locations.

Evolent Health is committed to the safety and wellbeing of all its employees, partners and patients and complies with all applicable local, state, and federal law regarding COVID health and vaccination requirements. Evolent expects all employees to also comply. We currently require all employees who may voluntarily return to our Evolent offices to be vaccinated and invite all employees regardless of vaccination status to remain working from home. Certain jobs require face-to-face interaction with our providers and patients in client facilities or homes. Employees working in such roles will be required to meet our vaccine requirements without exception or exemption.

Evolent Health is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability status.

Compensation Range:

The typical range of employees within the compensation grade of this position is . Salaries are determined by the skill set required for the position and commensurate with experience and may vary above and below the stated amounts.

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