Position Summary The Appeals Supervisor oversees day-to-day operations of the administrative (non-clinical)appeals. This role ensures timely, accurate, and compliant processing of member and provider administrative appeals in accordance with NCQA standards, contractual obligations, and organizational policies. The Supervisor leads a team responsible for documentation, review, correspondence generation, and workflow coordination non-clinical appeals. The position supports Commercial (PA & NJ), and Self-Funded (Level Care, BCBS Global Solutions (formerly GeoBlue)) products as well as external appeals for Caritas and collaborates closely with regulatory teams, quality, and operational partners to ensure high-quality appeal resolution and member experience. Key Responsibilities Leadership & Expertise
- Provides expertise, guidance, and technical support to the Administrative Appeals team to ensure compliance with NCQA and state requirements and organizational standards.
- Educates staff on new or updated procedures, NCQA and state rule changes, and internal process improvements; monitors adoption of procedures to ensure consistency and accuracy.
- Coaches, develops, and motivates staff to achieve performance expectations, maintain quality standards, and support regulatory adherence.
Appeals Operations Management
- Oversees daily workflow of Appeals Specialists to ensure administrative appeals are appropriately categorized (standard vs. expedited; pre-service vs. post-service; Caritas external appeals) and processed within required timeframes.
- Ensures timely and accurate execution of all appeal-related activities, including intake, triage, case creation, tracking, letter generation, and documentation within business systems.
- Provides initial research and guidance on specific appeal issues; applies administrative exception procedures consistently and in accordance with established guidelines.
- Oversees vendor support operations to ensure timely and accurate administrative appeals processing activities.
Compliance, Auditing & Quality Assurance
- Conducts regular audits of closed appeals files to confirm compliance with state requirements, NCQA standards, and internal processes; identifies root causes and recommends corrective actions.
- Ensures appeal outcome notices and correspondence adhere to state requirements and NCQA standards to ensure they reflect clear, professional, and member-friendly communication.
- Monitors the accuracy of data entry, classification, and documentation in appeals system.
Reporting & Workflow Optimization
- Reviews management reports and oversees inventory control to ensure turnaround times, productivity expectations, and staffing support the business needs.
- Identifies workflow barriers, analyzes trends, and recommends process improvements and policy adjustments to strengthen administrative appeals management.
- Collaborates with Business Analysts to maintain up-to-date templates and ensure system functionality supports regulatory requirements.
Cross-Department Collaboration
- Works closely with Clinical Appeals, Claims Operations, Customer Service, Provider Relations, Quality, and Compliance teams to ensure accurate and timely administrative appeal resolution.
- Participates in Quality Management Committees and organizational readiness activities related to state and NCQA audits, program reviews, and accreditation processes.
- Works with Caritas Appeals Leadership to ensure Caritas external appeals are received and works with the Bureau of Health Coverage Access, Administration, and Appeals (HCA3) to ensure Caritas External Appeals are submitted and processed timely by the assigned Independent Review Organization (IRO).
Process Management
- Develops, updates, and documents administrative appeals processes, procedures, and best practices to ensure standardized, compliant, and efficient resolution.
- Oversees the secure management, retention, and archival of administrative appeal records according to corporate and regulatory record-keeping standards.
- Performs additional duties as assigned to support administrative appeals operations and organizational goals.
- Bachelor's degree and at least 3 years of experience in customer service, health plan operations, appeals/grievances, or similar setting; OR in lieu of degree, 5 years of experience in an appeals role.
- Prior experience with appeals, grievances, compliance, or regulatory operations required.
- Leadership or supervisory experience preferred.
- Strong understanding of PA Act 146 as well as other state and NCQA regulatory requirements for appeals.
- Knowledge of Level Care and BCBS Global Solutions (formerly GeoBlue) products and operations strongly preferred but not required.
- Excellent leadership, organizational, interpersonal, written, and verbal communication skills.
- Proven ability to analyze workflows, prioritize competing tasks, and manage time-sensitive processes.
- Ability to work independently and collaboratively in a fast-paced, highly regulated environment.
- Experience in vendor operations is preferred.
- Demonstrated skill in motivating, coaching, and supporting staff development.
