LOB DESCRIPTION: Medical necessity review for appeals (Claims denied due to medical necessity)

JOB SUMMARY:

The Operations Manager for Appeals is responsible for managing and overseeing operations related to clinical appeals, ensuring compliance with industry standards and regulatory requirements. The role involves close collaboration with various stakeholders to drive performance and maintain high-quality standards.

QUALIFICATIONS:

• Bachelor’s Degree in Nursing with an active and valid license in PHRN
• Must have at least 1 or 2 years in a managerial role handling leaders/ TLs/ Supervisors
• Experience in managing teams handling Clinical Appeals
• Experience in handling appeals, utilization review, or related healthcare management functions
• Excellent verbal and written communication skills
• Willingness to work on-site with flexible schedules, including US hours and holidays
• Must not be a current or former employee of Concentrix

KEY RESPONSIBILITIES:

• Oversee daily operations and ensure compliance with SLAs and regulatory standards.
• Developer and implement process improvement initiatives.
• Collaborate with internal and client stakeholders to enhance service delivery and maintain accurate staffing.
• Ensure adherence to HIPAA and other regulatory requirements.