Job Summary

Accountability and supervisory of the daily coordination of Appeals. This position will supervise both inpatient post-acute and pre-service/elective appeals in conjunction with Medical Department programs/initiatives and company-wide policy.

Essential Functions

• Oversees the daily functioning of the care management and/or utilization management team (“team”), as assigned. Maintains current knowledge of all departmental activities.
• Responsible for the hiring, orientation, training and development, coaching, evaluation, and leadership of the team members. Systematically evaluates the quality and effectiveness of staff performance, analyzing appropriate data and information to identify areas for improvement.
• Plans, organizes, and implements collection of data and preparation of reports that support team functions and activities. Works with the Manager to identify barriers to smooth transition of workflow and cases between staff members.
• Develops and maintains expertise in regulatory, governmental, and accrediting requirements as they pertain to the team functions. Understands and holds staff accountable to all accrediting and regulatory expectations. Ensures compliance to case and disease management and/or utilization management functions (“team functions”) and processes, by assuring proper staff training, conducting and/or reviewing quality assurance and audit results, and taking appropriate action.
• Develops policies, procedures, and workflows to support team functions. Participates in the annual review of Medical Management policies and procedures. Ensures policies and procedures are current and that staff is trained accordingly.
• Provides input into the development, implementation and evaluation of departmental goals and objectives. Identifies opportunities for improvement and develops and implements solutions.
• Prioritizes work effectively and provides results in a timely manner.
• Collaborates with the Manager to develop and implement medical management programs that align with organizational strategies and allow Priority Health to achieve its key performance indicators. Keeps the Manager informed, as needed/appropriate.

How Corewell Health cares for you

• Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here.

• On-demand pay program powered by Payactiv
• Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!
• Optional identity theft protection, home and auto insurance, pet insurance
• Traditional and Roth retirement options with service contribution and match savings
• Relocation assistance

Qualifications

Required

• Bachelor's Degree or equivalent in nursing or a health-related field
• 7 years of relevant skills, knowledge, and experience in a clinical or health services setting
• 3 years of relevant knowledge of managed health care clinical programs and reporting
• LIC - Registered Nurse (RN) from the State of Michigan

Preferred

• 3 years of relevant prior leadership experience

About Corewell Health

As a team member at Corewell Health, you will play an essential role in delivering personalized health care to our patients, members and our communities. We are committed to cultivating and investing in YOU. Our top-notch teams are comprised of collaborators, leaders and innovators that continue to build on one shared mission statement - to improve health, instill humanity and inspire hope. Join a nationally recognized health system with an ambitious vision of continued advancement and excellence.

Primary Location

SITE - Priority Health - 1231 E Beltline - Grand Rapids

Department Name

PH - Inpatient Utilization Management

Employment Type

Full time

Shift

Day (United States of America)

Weekly Scheduled Hours

40

Hours of Work

8:00 a.m. to 5:00 p.m.

Days Worked

Monday to Friday

Weekend Frequency

N/A

CURRENT COREWELL HEALTH TEAM MEMBERS – Please apply through Find Jobs from your Workday team member account. This career site is for Non-Corewell Health team members only.

Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief.

Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.

An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team.

You may request assistance in completing the application process by calling 616.486.7447.