Appeals and Retros Clinical Manager

NHS South West London ICB is looking for an experienced, registered health professional to join our All Age Continuing Care (AACC) service as Appeals and Retros Clinical Manager.

Working alongside the Clinical Lead for Appeals and Retros, you will case manage appeals and retrospective assessments for the AACC service across south west London. You will liaise with clients, their families and representatives, and other key people, to make sure the National Framework for NHS Continuing Healthcare (CHC) and NHS-funded Nursing Care was applied correctly at the outset and that the appeals process is followed through each of its stages.

Where appropriate, you will represent the ICB at NHS England Independent Review Panels and make sure the learning from them is shared with AACC teams across the ICB. You will also deputise for the Clinical Lead, support the development of staff in the team, and help shape how the service develops.

You will bring strong CHC clinical assessment experience, an excellent working knowledge of the National Framework, and the ability to analyse complex and conflicting evidence and turn it into clear, well-reasoned recommendations. Experience of managing appeal and retrospective cases and presenting at Independent Review Panels would be an advantage.

Main duties of the job

• Triage all appeal and retrospective review referrals, liaising with applicants to make sure each referral holds enough information to trigger a full appeal or retrospective review.
• Manage a delegated caseload of CHC appeal and retrospective review cases, scrutinising clinical records, care plans, Decision Support Tools and MDT evidence against the National Framework, and prioritising work so that statutory and internal timescales are met.
• Write clear, evidence-based rationales, appeal summaries, case reviews and eligibility recommendations for Local Resolution Meetings, Independent Review Panels and internal governance panels.
• Represent SWL ICB AACC at Independent Review Panels hosted by NHS England, presenting cases with empathy and professionalism and offering assurance and apology where needed.
• Communicate sensitive and complex information, including diagnosis, prognosis and life-changing decisions, to clients, families, staff, NHS England and partner organisations.

Job responsibilities

• Quality assure Decision Support Tools, checklists and appeal documentation, and develop and monitor clinical standards, audit and peer review for the service.
• Act as an advocate for vulnerable people, challenging poor practice and discriminatory behaviour and escalating safeguarding and clinical concerns promptly.
• Track the financial risk linked to appeal and retrospective cases, and make sure any financial restitution is carried out promptly and in line with Standing Financial Instructions.
• Deputise for the Clinical Lead, support the allocation of the team's workload against KPIs, and contribute to staff recruitment, induction, appraisal, training and development.
• Support complaint investigations, policy and procedure development, training for health and care providers, and the sharing of best practice across the service.

Person Specification

• Registered health professional with current professional registration (e.g. NMC, HCPC)
• Degree or equivalent level of experience in health or social care
• Advanced clinical assessment skills
• Experience of operational service management, change management and service improvement, including leading successful projects
• Excellent knowledge of AACC national and local policy, including the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care, and working knowledge of all aspects of AACC (Clinical, Brokerage, Contracting, Finance, Business Intelligence and Quality)
• Ability to analyse very complex, conflicting information drawn from multiple sources, and to write comprehensive reports that can be understood by health and social care professionals and lay people
• Ability to communicate sensitive and complex decisions to clients, families, professionals and other stakeholders, and to manage conflict and challenging behaviour with tact, diplomacy and empathy