Clinical Appeals & Grievance Lead

Globalhealth Holdings

Oklahoma City (OK)

Hybrid

USD 75,000 - 110,000

Full time

14 days+

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Job summary

GlobalHealth is a Medicare Advantage HMO health insurer seeking a Nurse leader to manage Appeals & Grievances with clinical leadership and regulatory compliance. The role emphasizes timely resolution of member issues and strong reporting capabilities.

The position is remote in the US with minimal travel; requires an LPN license and 3 years A&G operations experience plus 2 years appeals/grievances experience. Proficiency in MS Office and reporting tools is expected.

Qualifications

LPN license required; associate or bachelor’s degree.
3 years A&G Clinical operations experience required.
2 years appeals and grievances required.
1 year experience with MS Office, Power BI a plus, Mitel or CRM (Epic) reporting apps required.

Responsibilities

Schedule and balance resources to match anticipated demand.
Monitor and oversight of appeals and grievances process.
Handle escalations for member issues.
Manage employee time and attendance.
Provide coaching and training of A&G team.
Provide daily reporting for critical measures.
Identify and execute opportunities for workflow improvement.
Manage daily workload for subordinates to ensure compliance.
Perform hiring, coaching and disciplinary actions as required.
Serve as primary Clinical representative and advocate for A&G in leadership meetings.
Maintain confidentiality of PHI as required by HIPAA and policy.
Performs 1st round Quality of Care reviews.
Performs other duties as assigned.