Manager, Clinical Appeals (Woodland Hills, CA)

Health Net, Inc. (NYSE: HNT) is among the nation’s largest publicly traded managed health care companies.  Health Net’s mission is to help people be healthy, secure and comfortable.  The company’s POS, HMO, insured PPO, behavioral health and government contracts subsidiaries provide health benefits to more than 7 million individuals.  For more information on Health Net, Inc., please visit the company’s Web site at www.healthnet.com JOB SUMMARY: The Manager Clinical Appeals plans, organizes and directs the work of licensed clinical specialists who resolve managed care appeals and grievance cases. Oversees processes to achieve departmental goals for timely, accurate and thorough case resolution, as prescribed by policies and procedures and regulatory and accreditation standards. Responsible for ensuring compliance with a highly regulated appeals and grievances process that has regulation and accrediting criteria for various state and federal bodies, including DMHC, CMS, DHS, Knox-Keene, and NCQA.  ESSENTIAL DUTIES AND RESPONSIBILITIES: With the Director, develops the annual department operational plan, including clearly identified goals and objectives and key operational initiatives. Plans, organizes, and directs the work activity of an Appeal and Grievance team to achieve timely, accurate and thorough resolution of A&G cases, meeting performance standards, compliance requirements, and goals and objectives. Develops team-specific work plans to meet performance and compliance standards. Aligns with the leadership team to review departmental productivity and performance reports for overall departmental results and trends to identify and implement performance improvement actions and key measures. Facilitates the timely review and resolution of administrative cases through appropriate designation and delegation of responsibility for case review and timely decision making. Aggregates, analyzes, and trends results of administrative case review to identify top root causes and to recommend potential actions for improvement to leadership. Communicates with plaintiff counsel and internal and external physicians who are advocating on behalf of members. Communicates with regulators, legislators, and attorneys on highly sensitive, escalated cases. Intercedes on issues escalated from other departments within the company regarding member issues with risk of litigation or arbitration and facilitates problem solving for favorable outcomes. Responsible for the selection, employment, promotion, associate performance evaluation, training, motivation, counseling, and discipline of assigned associates. Participates in the preparation of department budget and monitors and controls spending to ensure budget compliance. Promotes shared accountability interdepartmentally for overall business results in meeting regulatory requirements and compliance standards for A & G case resolution.  REQUIREMENTS: Education: Bachelor’s Degree in Nursing, Health Care Services, or other health related field required Certification/License: Unrestricted state of California Registered Nurse license required  Experience: Minimum five years experience in member relations, claims, or appeals and grievances Knowledge, Skills & Abilities: Demonstrated management skills and experience in a managed care setting required Excellent written and oral communication skills with strong analytical and problem solving skills Strong organizational skills and effective time management required Related knowledge and experience in process and performance improvement preferred Excellent computer literacy to navigate internal and external computer systems and softwareOR Any combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position. Health Net, Inc. supports a drug-free work environment and requires pre-employment background and drug screening. Health Net and its subsidiaries are an Equal opportunity/Affirmative Action Employer M/F/V/D.