Senior Clinical Appeals Supervisor - Government Programs

CareFirst BlueCross BlueShield; Baltimore (MD); Hybrid; USD 83,000 - 171,000; Full time

Benefits offered by this job

Hybrid work model

Job summary

CareFirst BlueCross BlueShield seeks a Clinical Appeals Supervisor for the Government Program Appeals and Grievance team in the greater Baltimore area. The role blends clinical leadership with regulatory oversight to ensure timely grievance and appeal resolutions in compliance with Federal and State mandates and NCQA standards.

The ideal candidate holds a BSN, an active RN license, and at least 5 years in utilization management or appeals.

Qualifications

• RN licensed in the appropriate state or compact state.
• Bachelor's degree in a related health discipline or BSN.
• Minimum 5 years of experience in utilization management or appeals processing.

Responsibilities

• Supervise 10–15 staff and ensure timely, compliant grievance resolution.
• Coordinate research and legal liaison for regulatory complaints and appeals.
• Develop procedures, onboarding, training, and performance reviews.
• Provide education to stakeholders and maintain knowledge base of current practices.

Skills

Regulatory knowledge

Appeals process understanding

Utilization management

Systems software knowledge

Education

Bachelor of Science in Nursing

Tools

CPT/HCPCS coding

Job description

CareFirst BlueCross BlueShield seeks a Clinical Appeals Supervisor for the Government Program Appeals and Grievance team in the greater Baltimore area. The role blends clinical leadership with regulatory oversight to ensure timely grievance and appeal resolutions in compliance with Federal and State mandates and NCQA standards.

The ideal candidate holds a BSN, an active RN license, and at least 5 years in utilization management or appeals.