Job Profile Summary

The Team Lead (TL) Clinical Correspondence is responsible for hands-on support and oversight of the clinical correspondence team. The TL will review correspondence and guide staff that compose, edit, and review written medical management determination letters across all Healthfirst managed care products. They will ensure that a wide variety of organizational determination letters to enrollees, providers and facilities including initial determination, fair hearing and detailed letters of denial across all product lines are clear, succinct and meet all NY State and/or CMS notice requirements. (This includes timeliness of notices and content). Will work in collaboration with care managers, the management team and peer reviewers to comply with regulatory-mandated notices. They will analyze/audit letters for appropriate medical terminology and use complying with organizational policies, as well as federal and state regulations governing organizational determinations. This will ensure corporate compliance with member, and provider written notices and reduce organizational risk for sanctions and non-conformance.

Duties/Responsibilities:

• Active involvement and leadership of the clinical correspondence team's day-to-day operations; ensuring that staff is consistent with Healthfirsts policies and procedures; and are in compliance with contractual, state and federal guidelines

• Supervises, analyzes and coordinates the unit's daily activities to ensure that departmental productivity goals are met with regards to quality, timeliness, accuracy and consistency of written communications

• Anticipates daily workload and explores opportunities for improved efficiencies without compromising quality of correspondence

• Collects data and analyzes trends in adverse determinations and timeliness of decision-making and notices.

• Communicates to management teams outcomes of analysis and collaboratively assists in development of improvement strategies for compliance with regulations

• Develops and monitors goals for employees, provides ongoing feedback and coaching.

• Ensures an atmosphere within the team that fosters open communication, teamwork, ownership and empowerment to make decisions

• Conducts performance reviews on an annual basis; coaches for performance; leads by example

• Participates in special projects initiated by the Manager.

• Assists Manager in coordinating regulatory, quality and accreditation activities

• Additional duties as assigned

Minimum Qualifications:

• High School Diploma or GED

• Work experience in a managed care environment

• Working experience in a fast-paced environment overseeing multiple tasks and supporting multiple team members

• Excellent written and verbal communication skills

• Flexibility to accommodate changes driven by contract requirements, benefit changes, and external drivers to process changes

Preferred Qualifications:

• Bachelors degree from an accredited institution

• Knowledge of CMS Chapter 13 and NY State PHL Article 44 & 49

• Leadership experience in managing, coaching, and developing employees.

• Critical/Creative Thinking and Problem-solving skills

• Adept at Planning, Organizing and Executing

• Strong technical skills to support clinical correspondence processing

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.