Oversee and manage Trillium’s provider appeals processes.
Supervise provider appeals staff and evaluate the effectiveness/efficiency of the department through regularly scheduled individual staff supervision and staff meetings.
Interface with vendors and internal business units to ensure compliance and good communication across the department.
Research, read and interpret controlling authority (coverage policies and service definitions, State and federal statutes and regulations, applicable contracts, agency policies & procedures, etc.).
Oversee accurate and complete files for each appeal with all documents used in decision making.
Prepare files for audits and reviews, including, but not limited to, external quality reviews and accreditation reviews.
Support staff in drafting appeal resolution letters in accordance with practices established by the Legal Department and ensure all appeals are processed and completed timely within accordance with legal and contractual and accreditation standards.
Prepare reports for internal and external stakeholders.

Associate’s degree and three (3) years’ experience in appeals, performing research under the guidance of an attorney or Legal Department, conducting compliance and risk management activities, and drafting correspondence in accordance with practices established by an attorney or Legal Department;
OR Bachelor’s degree and minimum one (1) year experience in appeals, performing research under the guidance of an attorney or Legal Department, conducting compliance and risk management activities, and drafting correspondence in accordance with practices established by an attorney or Legal Department;
OR Equivalent combination of education/experience.
Must have a valid driver’s license.
Must reside within North Carolina.
Must be able to travel within catchment as required.

Appeals Manager

Key skills