Manager, Appeals and Grievances

Your Future Evolves Here Evolent partners with health plans and providers to achieve better outcomes for people with most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of fragmented health care system and ensure people get the same level of care and compassion we would want for our loved ones. Evolent employees enjoy work/life balance, the flexibility to suit their work to their lives, and autonomy they need to get things done. We believe that people do their best work when they're supported to live their best lives, and when they feel welcome to bring their whole selves to work. That's one reason why diversity and inclusion are core to our business. Join Evolent for the mission. Stay for the culture.

What You’ll Be Doing: 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.

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.