Appeals Supervisor Resume Sample

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11 votes

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Adan Hirthe
90138 Grant Estates,  San Francisco, CA
+1 (555) 880 0238

Work Experience


Appeals Supervisor
09/2017 - PRESENT
Houston, TX
  • This is an in-house position in the Shelton CT office only
  • The primary duty is to oversee the production of member and provider appeal cases to ensure all requirements ((i.e. NCQA, URAC, EQRO, contractual, regulatory and judicial orders)) are met
  • Develop policy and procedures as well as performance standards by which to monitor the department’s progress
  • Ensure that all departmental policies, procedures, projects and departmental activities meet requirements of the applicable regulatory and accrediting agencies (i.e. NCQA, URAC, EQRO, contractual, regulatory and judicial orders)
  • Monitor the appeals volume and the number of appeals processed within the department to ensure both quality and adherence to the contractual regulations
  • Ensure effective communication of findings and activities takes place to the state agency, members, providers and inter-departmentally (throughout division and organization)
  • Ensure that each employee obtains monthly performance monitoring and evaluations to ensure productive feedback into employee development
Supervisor Appeals
10/2010 - 04/2017
San Francisco, CA
  • Monitor productivity and quality and implement appropriate actions to ensure department goals are met
  • Serve as department liaison for contact with support departments as well as the executive staff
  • Integrate pertinent information related to the member appeal procedures and data trends
  • Maintain a thorough knowledge of regulations, accreditation standards and corporate standards that affect the member grievance process
  • Monitor department standards, identify opportunities for improvement, recommend and implement appropriate actions to ensure goals are met
  • Prepare and conduct regular staff meetings
  • Oversee orientation of new appeals staff
  • Educate new and existing provider facing staff on compliance and appeals processes
  • Interact effectively with BCBST personnel within medical management, operations, Provider Networks and Contracting, and executive management as well as external members and providers
Supervisor, Appeals & Grievances
03/2004 - 05/2010
Boston, MA
  • Make decisions with little or no consultation with management
  • Adhoc projects as assigned by management
  • Coordinate and supervise daily / weekly / monthly activities of a 15 - 20 person team including setting priorities for the team to ensure task completion and performance goals are met
  • Provide coaching, feedback and annual performance reviews as well as formal corrective action
  • Analyze and identify trends for all appeals and grievances
  • Coordinate and supervise daily /weekly / monthly activities of a 20-25-person team including setting priorities for the team to ensure task completion and performance goals are met
  • Ensuring professional handling of all member and provider appeals for all lines of business
  • Ensuring that appeals and grievances meet NCQA, CMS, federal and state-mandated timelines
  • Overseeing scheduling, monitoring performance of Appeals/Grievance Specialists & the department as a whole

Education


Missouri Baptist University
1999 - 2004
School's Degree in Business

Professional Skills


  • Excellent computer skills with direct experience in MS office, Word, PowerPoint, and Excel required
  • Planning, organization and prioritization skills
  • Excellent written and oral communication skills (including presentation and team facilitation) required
  • Experience with insurance appeals OR Dental / Insurance Claims experience
  • Analytical and organizational skills and ability to meet deadlines
  • Experience with MS Excel including data entry, sorting, and creating / modifying spreadsheets
  • Experience in developing, leading and inspiring employees

How to write Appeals Supervisor Resume

Appeals Supervisor role is responsible for insurance, research, customer, health, leadership, articulate, mentoring, contracts, inventory, benefits.
To write great resume for appeals supervisor job, your resume must include:

  • Your contact information
  • Work experience
  • Education
  • Skill listing

Contact Information For Appeals Supervisor Resume

The section contact information is important in your appeals supervisor resume. The recruiter has to be able to contact you ASAP if they like to offer you the job. This is why you need to provide your:

  • First and last name
  • Email
  • Telephone number

Work Experience in Your Appeals Supervisor Resume

The section work experience is an essential part of your appeals supervisor resume. It’s the one thing the recruiter really cares about and pays the most attention to.
This section, however, is not just a list of your previous appeals supervisor responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular appeals supervisor position you're applying to. The work experience section should be the detailed summary of your latest 3 or 4 positions. Representative Appeals Supervisor resume experience can include:

  • Supervisory / managerial experience with direct reports
  • Hands on leadership experience in office and remote offices (Supervisor, Team Lead, Coach)
  • Experience with Healthcare / Medical terminology
  • Upervisory / Leadership experience
  • Claims, appeals or grievance experience
  • Navigate multiple systems and sites to validate and process information to retrieve data

Education on an Appeals Supervisor Resume

Make sure to make education a priority on your appeals supervisor resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your appeals supervisor experience. For example, if you have a Ph.D in Neuroscience and a Master's in the same sphere, just list your Ph.D. Besides the doctorate, Master’s degrees go next, followed by Bachelor’s and finally, Associate’s degree.

Additional details to include:

  • School you graduated from
  • Major/ minor
  • Year of graduation
  • Location of school
These are the four additional pieces of information you should mention when listing your education on your resume.

Professional Skills in Appeals Supervisor Resume

When listing skills on your appeals supervisor resume, remember always to be honest about your level of ability. Include the Skills section after experience. Present the most important skills in your resume, there's a list of typical appeals supervisor skills:

  • Experience analyzing and solving customer problems in an office environment
  • Experience analyzing and solving problems in an office, claims or customer service environment
  • Experience leading / coaching employees within a production environment is required
  • Experience working in a customer service role in a call center environment or in a claim or an appeals role
  • Experience in a Team Lead and/or Supervisory role
  • Appeals & Grievance or CTM experience

List of Typical Skills For an Appeals Supervisor Resume

1

Skills For Supervisor, Denials & Appeals Resume

  • Any experience with Microsoft Word (create, edit, and read documents), Microsoft Excel (create, edit, and read spreadsheets)
  • Experience in a supervisory role with direct reports within United Healthcare
  • Claims, appeals or grievance experience
  • Three (3) years’ experience in claims, utilization review, appeals or member services in a managed care environment
  • Working knowledge of healthcare claims, customer service, provider network contracting, and contract compliance
  • Providing cross department coverage for all lines of business
  • Working knowledge of A&G process
  • Physicalrequirements include but are not limited to walking, lifting (20 lbs.), standing,bending, and sitting for extended periods of time
  • Manages Provider Appeals through each stage of appeal to resolution, including adhering to all turn around times
2

Skills For Supervisor Appeals Resume

  • Plan and facilitate meetings including team meeting, staff meetings and the Appeals Committee meetings
  • Assist the management team during the interview and hiring process
  • Provides support to the work done in all lines of business (TMP and Commercial) including weekend coverage
  • Knowledge of current state, federal legislation and accrediting body standards
  • Participate in the development of appeal standard operating procedures under the direction of the Manager of Administrative Appeals
  • Make recommendations on those that best meets project, department and corporate objectives
  • Be flexible and a proponent of change. Ability to envision the impact of change and ways to do business
  • Demonstrated ability to synthesize and process complex information and deliver the information, both verbally and written, in a clear, concise, and articulate manner. Requires strong verbal and written skills to effectively communicate at both detail and summary levels to THP management
  • Coordination of benefits and which plan is primary - simple and complex cases (commercial plans, Medicare plans) Pharmacy benefits including injectable medications
3

Skills For Appeals Operations Supervisor Resume

  • Responsible for developing and implementing policies and procedures to ensure compliance with all regulatory requirements
  • Ensures professional handling of all member and provider appeals
  • Hires, trains and supervises the Appeals/Grievance Specialists & the department as a whole
  • Supervises assigned employees responsible for the submission, research, and resolution of provider inquiries and/or disputes for the Plan. Ensures resolutions are compliant
  • Oversees researches and documents each Provider Appeal. Ensures resolution is compliant
  • Coordinates workflows between departments and interfaces with internal and external resources
  • Serves as primary interface with Corporate counterparts and ensures standard processes are implemented
4

Skills For Supervisor, Appeals & Grievances Resume

  • Prepares or supervises the preparation of narratives, graphs, flowcharts, etc. to be used for committee presentations, audits and internal/external reports
  • Supervises preparation of necessary correspondence in accordance with regulatory requirements
  • Maintains call tracking system of correspondence and outcomes for provider inquiries/disputes; monitors provider submission/resolution to ensure all internal and regulatory timelines are met
  • Provides oversight of appeal policies and procedures specific to benefits, contracts and State requirements
  • Knowledge of managed care products
  • Knowledge and familiarity of national accreditation standards, specifically NCQA and URAC standards
  • Knowledge of state and federal health care and health operations regulations
  • Interface staff across organizational lines as well as with members and providers
  • Registered Nurse (RN) with current, unrestricted license in the state of operations
5

Skills For Supervisor of Appeals Resume

  • Experience using a computer and Microsoft Office including Microsoft Word (create correspondence and work within templates), Microsoft Excel (data entry, sort / filter, and work within tables), and Microsoft Outlook (email and calendar management)
  • Supervisory / Leadership experience
  • Experience in a supervisory role with direct reports
  • Work with Manager to ensure that employees have the requisite information and knowledge of regulatory issues and requirements to carry out their responsibilities in a lawful and ethical manner
  • Continuously build department infrastructure to meet complex and changing compliance needs
  • Coordinate and supervise daily / weekly / monthly activities of a 20-25-person team including setting priorities for the team to ensure task completion and performance goals are met
  • Direct supervision of Administrative Appeals Coordinators
6

Skills For Supervisor, Provider Appeals Resume

  • Schedule, coordinate and lead the day-to-day activities of the Department to ensure that adequate resources are in place to meet the departmental timeliness expectations and various client performance expectations. Deliver excellent service via departmental telephone accessibility and inquiry management
  • Assist with the documentation of performance expectations and review those expectations and achievements with each staff member in accordance with company guidelines. Assist with the development and implementation of staffing plans that include clear objectives
  • Relevant Work Experience: 3 years of experience in the health care/health insurance field is required
  • Supervise the receipt, investigation and resolution of escalated issues in a timely and highly effective manner
  • Appeals review experience
  • Facilitate regular staff meetings for dissemination of operational and administrative information to the staff
  • Identify and monitor trends in utilization and quality metrics of Administrative Appeals
7

Skills For Supervisor Appeals / Denials Resume

  • Assist the Manager of Administrative Appeals in the interpretation of UM metrics specific to Administrative Appeals for the organization and individual contracts
  • Oversee appeal processes related to Administrative Appeals to ensure compliance with Beacon’s policy guidelines, external regulatory requirements and URAC/NCQA accreditation standards
  • Assist staff in the application of standard operating procedures for appeal review
  • Collaborate with Beacon Appeals & Retros clinical supervisors to establish best practices and standardize workflows for overall management of appeals cases
  • Monitor productivity, timeliness, and quality standards for team of Administrative Appeals Coordinators
8

Skills For Supervisor Appeals & Grievance / CTM Quality Resume

  • Participate in new business implementations as assigned
  • Maintain thorough knowledge of covered benefits for the populations served
  • Ensure performance management tools are consistently utilized to increase productivity and quality service while serving as a role model for staff. Supervise quality control functions to ensure that all inquiry resolutions are handled accurately and timely to minimize customer re-contacts and inventory backlogs. Ensure telephone/written inquiry quality in all interactions with the customer

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