RN Manager, Grievances and Appeals

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

General Summary of Position

Responsible for day to day oversight and management of Intake Clinical Appeals Claims Appeals Complaints Grievances and Intake functions. The Manager of Appeals Complaints and Grievances will be dedicated to delivering service and operational excellence through a focus on continuous improvement in the areas of contribution competencies and performance of the Intake Appeals Complaints and Grievances team. This role will be tasked with overseeing intake the development and operational execution of all appeals (clinical and non-clinical) complaints and grievance processes in line with regulatory standards while enhancing quality and effectiveness. Additionally the role will need to utilize advanced technical knowledge to resolve complex issues. This involves setting objectives creating policies and procedures determining approaches allocating resources and managing inventory.

Primary Duties and 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. Ensures appropriate data collection and timely submission.
• Develops and contributes to the achievement of established department goals and objectives and adheres to department policies procedures quality standards and safety standards. Ensures compliance with hospital/facility policies and procedures and governmental/accreditation regulations.
• Actively participates with annual strategic planning objectives for MedStar Family Choice. Initiates innovative ideas and programs to improve quality while maintaining or reducing medical expense.
• 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. Maintains close affiliation with the support service team to ensure the system operations meet departmental functions troubleshoots issuers coordinates testing for system upgrades and coordinates appropriate training for associates. Acts as a resource to staff using the software.
• Oversees the selection orientation training program and assignment of new and current associates. Maintains up to date training manuals for assigned departments.
• Develops standards of performance evaluates performance and conducts performance management planning. Initiates or makes recommendations for personnel actions. Maintains ongoing communication with subordinates to review programs provide feedback discuss new developments and exchanges information.
• Participates in multidisciplinary quality and service improvement teams as appropriate. Participates in meetings serves on committees and represents the department and hospital/facility in community outreach efforts as appropriate.
• Performs other duties as assigned.

Minimal Qualifications

Education

• Bachelor’s degree in Nursing required

Experience

• Experience with appeals and grievances required
• Experience in Medicaid with an MCO (Managed Care Organization) required
• 3-4 years Utilization management experience required and
• 5-7 years Diverse clinical experience in a hospital or medical setting required and
• 2 years supervisory experience required
• 2 days onsite per week required

Licenses and Certifications

• RN – Registered Nurse – State Licensure and/or Compact State Licensure Valid RN license in the State of Maryland upon hire and valid RN licensure in the District of Columbia (DC) prior to start date in position. Upon Hire required and
• CCM – Certified Case Manager Active Certified Case Manager (CCM) or CCM certification within 1 Year required

Knowledge Skills and Abilities

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

This position has a hiring range of USD $102,606.00 – USD $196,996.00 /Yr.

In addition to your salary, MedStar Health offers a comprehensive healthcare package (including medical, dental and vision subject to eligibility requirements) and other benefits. The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by MedStar Health. MedStar Health is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.

The hiring range is the range MedStar Health, in good faith, believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on work experience, education and/or skill level, etc. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in MedStar Health’s sole discretion unless and until paid and may be modified at MedStar Health’s sole discretion, consistent with the law.

Why MedStar Health?

At MedStar Health, we understand that our ability to treat others well begins with how we treat each other. We work hard to foster an inclusive and positive environment where our associates feel valued, connected, and empowered. We live up to this promise through:

• Strong emphasis on teamwork—our associates feel connected to each other and our mission as an organization. In return, our effective team environment generates positive patient outcomes and high associate satisfaction ratings that exceed the national benchmark.
• Strategic focus on equity, inclusion, & diversity—we are committed to equity for all people and communities. We continue to build a diverse and inclusive workplace where people feel a sense of belonging and the ability to contribute to equitable care delivery and improved community health outcomes at all levels of the organization.
• Comprehensive total rewards package—including competitive pay, generous paid time off, great health and wellness benefits, retirement savings, education assistance, and so much more.
• More career opportunities closer to home—as the largest healthcare provider in the Baltimore-Washington, D.C. region, there are countless opportunities to grow your career and fulfill your aspirations.

About MedStar Health

MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, D.C. region, while advancing the practice of medicine through education, innovation, and research. Our team of 32,000 includes physicians, nurses, residents, fellows, and many other clinical and non-clinical associates working in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest home health provider in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar Health is dedicated not only to teaching the next generation of doctors, but also to the continuing education, professional development, and personal fulfillment of our whole team. Together, we use the best of our minds and the best of our hearts to serve our patients, those who care for them, and our communities. It’s how we treat people.

MedStar Health is an Equal Opportunity (EO) Employer and assures equal opportunity for all applicants and employees. We hire people to work in different locations, and we comply with the federal, state and local laws governing each of those locations. MedStar Health entities that are federal government contractors are Equal Opportunity and affirmative Action employers. MedStar Health makes all decisions regarding employment, including for example, hiring, transfer, promotion, compensation, benefit eligibility, discipline, and discharge without regard to any protected status, including race, color, creed, religion, national origin, citizenship status, sex, age, disability, veteran status, marital status, sexual orientation, gender identity or expression, political affiliations, or any other characteristic protected by federal, state or local EO laws. If you receive an offer of employment, it is MedStar Health’s policy to hire its employees on an at-will basis, which means you or MedStar Health may terminate this relationship at any time, for any reason.