Manager, Appeals and Grievances

Your Future Evolves Here

The Specialty Appeals Team offers candidates the opportunity to make a meaningful impact as part of a highly trained dedicated team focusing on appeals and post-determination requests. We maintain the principles of utilization management by adhering to Evolent and Client policies and procedures while complying with timeliness guidelines. Our team values collaboration, continuous learning, and a customer-centric approach, ensuring that every team member contributes to providing better health outcomes for the Clients and Members we serve.

Collaboration Opportunities:

The manager collaborates both internally and externally on the Team. They interact with the Director for guidance, policy updates, new Client Implementations, and much more. The also guide the Lead Coordinators for team daily oversight assistance and support on all tasks including triage/assignments/case review questions; and Coordinators for overall management, monitoring for trends and review of metrics. The Appeals teamwork strategies and opportunities for collaboration include all-team and individual team meetings, Teams chats, and monthly communication on team metrics and accomplishments.

What You Will Be Doing:

• Monitors and manages intake for Specialty appeals, cases needing second level medical necessity review and escalated questions. Oversight of non-clinical staff including training, performance management, and case guidance.

• Manages staff by monitoring staff production and adherence to departmental standards and expectations. Monthly Team Meetings, individual monthly 1:1’s, monitoring productivity.
• Facilitates the timeliness and accuracy standards adhering to client, state and federal requirements.
• Organizes volume of work and manages work assignments of staff.
• Assists with providing employee training on different specialized task processes.
• Assists in the development of department workflows and implementations.
• Consults with clinical and/or claims staff on problem cases and interfaces with all departmental staff in resolving denial, appeal, provider dispute issues and/or grievances/complaints.
• Assists in the data gathering and analysis of reports regarding appeal and provider dispute activity, as well as preparation for audits.
• Oversees staff intake of calls related to appeal filing and case questions.

•  Provides direction to Senior Coordinators assigned to your team.

What You Bring:

• Management experience in a Health Care Setting, preferably Utilization Management is required.

• Minimum of 5 years in Utilization Management, health care Appeals, compliance and/or grievances/complaints in a quality improvement environment is required.

• Strong verbal and written communication skills.

• Working knowledge of Microsoft Office Product Suit.

Technical Requirements:

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 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. If you need reasonable accommodation to access the information provided on this website, please contact recruiting@evolent.com for further assistance.