Manager, Appeals/Resolution

Summary

The Manager, Appeals is responsible for the operational oversight, regulatory compliance, performance management, and continuous improvement of the health plan's Appeals Department. This role leads the administration of member and provider appeals across Commercial, Self-Funded (ASO), and Medicare Advantage lines of business, ensuring timely, accurate, and compliant adjudication of all appeals in accordance with federal and state regulations, CMS requirements, contractual obligations, and organizational policies.

Job description

Requirements

• Minimum 5 years of progressive healthcare payer experience
• Minimum 5 years of leadership experience managing appeals, grievances, utilization management, claims, or related healthcare operations
• Experience supporting Medicare Advantage plans required
• Experience with Commercial and Self-Funded health plan operations required
• BS business administration, health administration, management, or equivalent experience
• Knowledge of State and Federal regulations as they pertain to the health insurance industry
• Experience with STAR ratings, care cap reports and risk scores
• Knowledge of CMS, NCQA, and HEDIS regulations as they pertain to the health insurance industry
• Proven experience reviewing and analyzing statistical data to identify trends as well as potential problems/opportunities for improved service quality
• Versed in processes improvement techniques to reduce waste, and achieve efficiencies through simplifying complex processes within the department
• Ability to develop, use, interpret and apply key business metrics required
• Ability to organize and lead key initiatives required
• Knowledgeable of developing and implementing training for adult learners
• Strong written and verbal communication with an ability to effectively communicate with all types/levels of audiences required
• Experienced presentation skills and versed in public speaking
• Detail oriented; analytical ability; strong problem-solving skills required
• Advanced proficiency with all Microsoft Office Suite (Excel, Word, Visio, Outlook), and budgetary, time and attendance (Kronos) software systems
• Resourceful and innovative in overcoming challenges through adapting, and responding quickly to change to gain efficiencies and increase productivity
• Must be able to make independent decisions, multi-task, prioritize tasks, and work with other internal departments to meet company goals

Benefits

• Loan Forgiveness Program
• Competitive Compensation
• Generous Paid Time Off
• Medical, Dental, Vision
• Prescription Drug Plans
• 401(k) with company match
• Discounted stock plan
• SoFi Student Loan Refinancing
• Career development opportunities

Company overview

Universal Health Services, Inc. (UHS) is one of the nation's largest and most respected providers of hospital and healthcare services, operating as a Fortune 300 corporation headquartered in King of Prussia, Pennsylvania. Founded in 1979, UHS has grown into a major healthcare enterprise with approximately 99,000 employees and annual revenues exceeding $14 billion. The company operates through its subsidiaries, managing 29 acute care hospitals, 331 behavioral health facilities, and 60 outpatient and other facilities across 39 U.S. states, Washington D.C., Puerto Rico, and the United Kingdom. UHS provides comprehensive healthcare services including acute care, behavioral health treatment, cancer centers, and ambulatory surgical centers. The company's strategy focuses on building or acquiring high-quality hospitals in rapidly growing markets and investing in advanced medical equipment and skilled personnel to become the leading healthcare provider in each community it serves. UHS is publicly traded on the New York Stock Exchange (NYSE: UHS) and has established a strong reputation for delivering compassionate, high-quality care while maintaining financial stability and operational excellence.