RN Manager: Appeals & Grievances Operations

Communityplans; Washington (District of Columbia); Hybrid; USD 103,000 - 197,000; Full time

Job summary

MedStar Health in the Washington, D.C. area seeks a Manager of Appeals, Complaints and Grievances to oversee Intake, Appeals, and Clinical Complaints, with a focus on service excellence and regulatory compliance.

Responsibilities include leading a multidisciplinary team, ensuring NCQA/EQRO standards, and partnering with IT to support the clinical software system; requires RN licensure and CCM certification.

Qualifications

• Excellent verbal and written communication skills.
• Proficient in Microsoft Word Excel and PowerPoint.

Responsibilities

• Oversees and provides direction for Intake Appeals (Clinical and Claims) Retrospective Review Emergency Room Review and Customer Service/Complaints/Grievances for all lines of business.
• Oversees and analyzes critical data and reporting as required by MedStar Family Choice for areas of responsibility.
• Develops and contributes to the achievement of established department goals and objectives and adheres to department policies procedures quality standards and safety standards.
• Actively participates with annual strategic planning objectives for MedStar Family Choice.
• Provides oversight to ensure that retrospective events appeals and complaints/grievances timeframes are in compliance with NCQA EQRO State of Maryland District of Columbia Federal and any other applicable standards.
• Maintains working knowledge of MFC authorization rules for MD and DC and facilitates appropriate training to ensure that MFC associates practitioners facilities and vendors are aware of authorization rules.
• Acts as the clinical liaison with IT and subject matter expert for Appeals Grievances and Customer Service with respect to the clinical software system.
• Oversees the selection orientation training program and assignment of new and current associates.
• Develops standards of performance evaluates performance and conducts performance management planning.
• Participates in multidisciplinary quality and service improvement teams as appropriate.
• Performs other duties as assigned.

Skills

Verbal and written communication

Microsoft Word, Excel, PowerPoint

Education

Bachelor's degree in Nursing

Job description

MedStar Health in the Washington, D.C. area seeks a Manager of Appeals, Complaints and Grievances to oversee Intake, Appeals, and Clinical Complaints, with a focus on service excellence and regulatory compliance.

Responsibilities include leading a multidisciplinary team, ensuring NCQA/EQRO standards, and partnering with IT to support the clinical software system; requires RN licensure and CCM certification.