Children's National Medical Center
Manager of Appeals and Grievances
Children's National Medical Center, Washington, District of Columbia, us, 20022
Job Title:
Manager of Appeals and Grievances (2400023U)Description:
This position manages the day-to-day operations of the Appeals and Grievances operations for our Medicaid Health Plan - HSCSN. Assures that the department is compliant with all regulatory requirements, manages turnaround times, submits reports to the executive leadership team, and develops strategies to improve processes. This position has three direct reports and is a hybrid telework position.Qualifications:Bachelors Degree in healthcare related field - preferredMaster's Degree - preferred5 years Appeals and Grievances experience - required3 years Managed Care experience - required3 years Acute, Med-Surg, or Ambulatory care experience in a clinical role - preferredRequired Licenses:Registered Nurse DC preferred/Compact - preferredRequired Skills/Knowledge:Knowledge of health care evaluation methodology, medical terminology, and regulationsStrong organizational, analytical, and data management skills, including word processing, spreadsheets, monitoring and evaluation toolsDetail oriented and organized with a strong sense of follow-up and completionExperience using time management skills to prioritize/organize and track details and deadlines of multiple projects with varying completion datesClinical experience that has been either recent, lengthy/and/or diverseAwareness of health care industry trends and strategiesFluency in electronic medical record documentation of clinical careClinical experience with acute care and ambulatory care operationsKnowledge of InterQual criteriaAbility to communicate effectively (verbal and written) with individuals internal and external to the organizationConflict Management skills and self-confidence for resolution of outcomes with dissatisfied patients/customers or those for which an outcome was sub-optimalExpert verbal and written communication and presentation skillsStrong analytical, organizational, and interpersonal skillsAdvanced proficiency with Outlook, Microsoft Excel, and Word applicationsResponsibilities:Supervise the Grievance and Appeals team to ensure appropriate handling of member appeals and grievancesServe as the organization’s subject matter expert on the Chart Retrieval & Clinical Review platform, including interactions with and impacts on adjacent services. Maintain appropriate documentation to meet regulatory reviewsEnsure that all appeals and grievances are investigated thoroughly and resolved in compliance with regulatory requirementsConduct periodic reviews and audits to ensure quality and performance standards are metDevelop and maintain records of appeals and grievances for reporting and auditing purposesPrepare and submit documents in response to fair hearings processes and requests; engage internal legal counsel as necessaryPrepare and develop reports for, and present to, management related to appeals and grievances and fair hearingsEnsure strict adherence to contractual requirements and Medicaid regulations, policies, and proceduresStay informed about changes in health care regulations related to appeals and grievances, and update processes accordinglyPrepare and submit required reports to regulatory authorities regarding appeals, grievances and fair hearings activitiesProvide guidance, mentorship, and training to appeals, grievances, and risk management staffFoster a culture of compliance, quality improvement, and patient-centered careIdentify potential conflicts when reviewing and resolving appeals and grievances and escalate such conflicts to appropriate leader for review and resolutionMay perform other duties in addition to those outlined in this job descriptionDC RESIDENTS ENCOURAGED TO APPLYPrimary Location:
District of Columbia-WashingtonWork Locations:
HSCSN - Vermont Ave, 1101 Vermont Ave NW, Washington, 20005Job:
Non-Clinical ProfessionalOrganization:
HSC W/Special NeedsPosition Status: R (Regular) - FT - Full-TimeShift: DayWork Schedule: M-F 9-5Job Posting:
Sep 3, 2024, 2:47:38 PMFull-Time Salary Range:
93974.4 - 156603.2Health Services for Children with Special Needs (HSCSN) is an equal opportunity employer that evaluates qualified applicants without regard to race, color, national origin, religion, sex, age, marital status, disability, veteran status, sexual orientation, gender identity, or other characteristics protected by law.Please note that it is the policy of Health Services for Children with Special Needs (HSCSN) to ensure a “drug-free” work environment.
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Manager of Appeals and Grievances (2400023U)Description:
This position manages the day-to-day operations of the Appeals and Grievances operations for our Medicaid Health Plan - HSCSN. Assures that the department is compliant with all regulatory requirements, manages turnaround times, submits reports to the executive leadership team, and develops strategies to improve processes. This position has three direct reports and is a hybrid telework position.Qualifications:Bachelors Degree in healthcare related field - preferredMaster's Degree - preferred5 years Appeals and Grievances experience - required3 years Managed Care experience - required3 years Acute, Med-Surg, or Ambulatory care experience in a clinical role - preferredRequired Licenses:Registered Nurse DC preferred/Compact - preferredRequired Skills/Knowledge:Knowledge of health care evaluation methodology, medical terminology, and regulationsStrong organizational, analytical, and data management skills, including word processing, spreadsheets, monitoring and evaluation toolsDetail oriented and organized with a strong sense of follow-up and completionExperience using time management skills to prioritize/organize and track details and deadlines of multiple projects with varying completion datesClinical experience that has been either recent, lengthy/and/or diverseAwareness of health care industry trends and strategiesFluency in electronic medical record documentation of clinical careClinical experience with acute care and ambulatory care operationsKnowledge of InterQual criteriaAbility to communicate effectively (verbal and written) with individuals internal and external to the organizationConflict Management skills and self-confidence for resolution of outcomes with dissatisfied patients/customers or those for which an outcome was sub-optimalExpert verbal and written communication and presentation skillsStrong analytical, organizational, and interpersonal skillsAdvanced proficiency with Outlook, Microsoft Excel, and Word applicationsResponsibilities:Supervise the Grievance and Appeals team to ensure appropriate handling of member appeals and grievancesServe as the organization’s subject matter expert on the Chart Retrieval & Clinical Review platform, including interactions with and impacts on adjacent services. Maintain appropriate documentation to meet regulatory reviewsEnsure that all appeals and grievances are investigated thoroughly and resolved in compliance with regulatory requirementsConduct periodic reviews and audits to ensure quality and performance standards are metDevelop and maintain records of appeals and grievances for reporting and auditing purposesPrepare and submit documents in response to fair hearings processes and requests; engage internal legal counsel as necessaryPrepare and develop reports for, and present to, management related to appeals and grievances and fair hearingsEnsure strict adherence to contractual requirements and Medicaid regulations, policies, and proceduresStay informed about changes in health care regulations related to appeals and grievances, and update processes accordinglyPrepare and submit required reports to regulatory authorities regarding appeals, grievances and fair hearings activitiesProvide guidance, mentorship, and training to appeals, grievances, and risk management staffFoster a culture of compliance, quality improvement, and patient-centered careIdentify potential conflicts when reviewing and resolving appeals and grievances and escalate such conflicts to appropriate leader for review and resolutionMay perform other duties in addition to those outlined in this job descriptionDC RESIDENTS ENCOURAGED TO APPLYPrimary Location:
District of Columbia-WashingtonWork Locations:
HSCSN - Vermont Ave, 1101 Vermont Ave NW, Washington, 20005Job:
Non-Clinical ProfessionalOrganization:
HSC W/Special NeedsPosition Status: R (Regular) - FT - Full-TimeShift: DayWork Schedule: M-F 9-5Job Posting:
Sep 3, 2024, 2:47:38 PMFull-Time Salary Range:
93974.4 - 156603.2Health Services for Children with Special Needs (HSCSN) is an equal opportunity employer that evaluates qualified applicants without regard to race, color, national origin, religion, sex, age, marital status, disability, veteran status, sexual orientation, gender identity, or other characteristics protected by law.Please note that it is the policy of Health Services for Children with Special Needs (HSCSN) to ensure a “drug-free” work environment.
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