RN Manager Grievances & Appeals

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

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.

About The Job

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.

Education

• Bachelor's degree in Nursing required

Experience

• Additional experience with appeals and grievances required
• 3-4 years Utilization management experience required and
• 5-7 years Diverse clinical experience in a hospital or medical setting required and
• 1-2 years 2 years supervisory experience 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.