Director Member and Provider Appeals
Job Posting for Director Member and Provider Appeals at Cambia Health Solutions
Director Member and Provider Appeals
Remote in Washington, Oregon, Utah or Idaho
Primary Job Purpose
Provides leadership for operational areas within Clinical Services including functions such as Medical Management (Prior Authorization and IP Concurrent Review), Member and Provider Appeals, Vendor Management, and Project Implementation. Participates on the Clinical Services Leadership Team and helps drive effective systems and processes, operational reporting, regulatory compliance, and business and clinical results.
General Functions and Outcomes
- Provides leadership in developing, implementing, and communicating short and long-range plans, goals, and objectives. Aligns team goals with the organization’s vision and strategy, federal and state law and regulations, accreditation standards, and client requirements.
- Develops and implements systems, policies and procedures for areas managed. Analyzes work flows to optimize business process and compliance, identifies system business requirements and continuously improves processes and outcomes.
- Manages the organization by ensuring clear performance expectations along with appropriate skills sets. Fosters an effective work environment and ensures employees receive recognition, feedback and development. Participates in organizational talent management and succession planning.
- Determines appropriate staffing levels and resource needs, creates and manages department and/or project budget, allocates resources, and approves expenditures. Manages quality and successful outcomes of functions or projects.
- Makes recommendations as to the use and selection of external vendors. Provides leadership and operational oversight to vendors, ensuring quality, cost and efficiency goals are attained.
- Partners with leaders across Health Care Services, multiple lines of business, and other functional areas of the organization to develop, lead and oversee clinical operations and related programs.
- Ensures compliance with and participates in legislative initiatives and mandates including but not limited to federal, HIPAA, state mandates and URAC.
- Oversees the production and delivery of high-impact, timely reports that support clinical services and demonstrate the value of clinical programs and services.
- Advocates for effective and efficient technology solutions for clinical services staff and for clinical programs. Provides leadership to develop new process and system capabilities.
Minimum Requirements
- Knowledge of health insurance industry trends and technology including familiarity with clinical program management and related functional and operational areas.
- Demonstrated ability to develop and lead high performing teams, manage managers, and direct vendors.
- Strong communication and facilitation skills with all levels of the organization, including the ability to resolve issues and build consensus among groups of diverse stakeholders.
- General business acumen including understanding of market dynamics, financial/budget management, data analysis and decision making.
- Proficiency with healthcare data, technology, and data reporting systems.
- Demonstrated ability to create and execute operationally efficient and cost-effective programs and drive results across internal teams and/or external vendors.
- Extensive knowledge of CMS and state regulatory requirements and demonstrated ability to manage compliant operations. NCQA, URAC and/or HEDIS accreditation experience strongly preferred.
- Familiarity with clinical terminology and data. Direct clinical background or licensure preferred.
Normally to be proficient in the competencies listed above
Director Clinical Services Operations would have a Bachelor’s degree in healthcare, business or related field, ten years of experience in a health insurance environment (to include utilization management, clinical intake/customer service, health information management, and/or quality improvement) and five years leadership experience or equivalent combination of education and experience.
Work Environment
Work primarily performed in remote setting.
Travel may be required – locally or out of state.
May be required to work outside of normal hours.
Travel may be required – locally or out of state.
May be required to work outside of normal hours.
#LI-Remote
The expected hiring range for a Director Member and Provider Appeals is $159,800 - $216,200 depending on location, skills, experience, education, and training; relevant licensure / certifications; performance history; and work location. The bonus target for this position is 25% . The current full salary range for this role is $150,000 - $245,000.
Base pay is just part of the compensation package at Cambia that is supplemented with an exceptional 401(k) match, bonus opportunity and other benefits. In keeping with our Cause and vision, we offer comprehensive well-being programs and benefits, which we periodically update to stay current. Some highlights:
- medical, dental, and vision coverage for employees and their eligible family members
- annual employer contribution to a health savings account ($1,200 or $2,500 depending on medical coverage, prorated based on hire date)
- paid time off varying by role and tenure in addition to 10 company holidays
- up to a 6% company match on employee 401k contributions, with a potential discretionary contribution based on company performance (no vesting period)
- up to 12 weeks of paid parental time off (eligible day one of employment if within first 12 months following birth or adoption)
- one-time furniture and equipment allowance for employees working from home
- up to $225 in Amazon gift cards for participating in various well-being activities. for a complete list see ourExternal Total Rewardspage.
We are an Equal Opportunity and Affirmative Action employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A background check is required.
If you need accommodation for any part of the application process because of a medical condition or disability, please email
CambiaCareers@cambiahealth.com
. Information about how Cambia Health Solutions collects, uses, and discloses information is available in our Privacy Policy
. As a health care company, we are committed to the health of our communities and employees during the COVID-19 pandemic. Please review the policy on our Careers
site.
Salary.com Estimation for Director Member and Provider Appeals in Renton, WA
$108,976 to $140,722
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