RN Manager: Appeals, Grievances & Clinical Quality

MedStar Health; Columbia (MD); On-site; USD 103,000 - 197,000; Full time

Job summary

MedStar Health is seeking a nurse leader to oversee Intake Clinical Appeals, Complaints and Grievances. This role focuses on service excellence, policy development, and regulatory compliance across all lines of business in Maryland/DC.

The manager will guide data analytics, set objectives, allocate resources, and ensure adherence to NCQA and other standards while driving quality improvements and operational efficiency.

Qualifications

• RN license in Maryland upon hire and DC license prior to start date
• CCM certification to be achieved within 1 year
• Strong leadership and communication skills required

Responsibilities

• Oversees Intake Appeals (Clinical and Claims), Retrospective Review, ER Review and Customer Service/Complaints/Grievances for all lines of business.
• Analyses critical data and reporting; ensures data collection and timely submission.
• Develops and supports department goals; ensures compliance with policies, standards, and regulations.
• Plans strategically; initiates quality improvement programs to reduce medical expense while maintaining quality.
• Ensures compliance with NCQA EQRO, state, district, federal standards and other regulators for appeals and grievances.
• Provides training to staff on authorization rules and clinical software systems; coordinates system testing and upgrades.
• Manages staff orientation; maintains training manuals; conducts performance reviews.
• Participates in multidisciplinary quality and service improvement teams; represents department externally as needed.
• Performs additional duties as assigned.

Skills

Leadership

Communication

MS Office

Education

Bachelor's degree in Nursing

Job description

MedStar Health is seeking a nurse leader to oversee Intake Clinical Appeals, Complaints and Grievances. This role focuses on service excellence, policy development, and regulatory compliance across all lines of business in Maryland/DC.

The manager will guide data analytics, set objectives, allocate resources, and ensure adherence to NCQA and other standards while driving quality improvements and operational efficiency.