Manager of Appeals and Grievances

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:

1. Bachelors Degree in healthcare related field - preferred
2. Master's Degree - preferred
3. 5 years Appeals and Grievances experience - required
4. 3 years Managed Care experience - required
5. 3 years Acute, Med-Surg, or Ambulatory care experience in a clinical role - preferred

Required Licenses:

Registered Nurse DC preferred/Compact - preferred

Required Skills/Knowledge:

1. Knowledge of health care evaluation methodology, medical terminology, and regulations
2. Strong organizational, analytical, and data management skills, including word processing, spreadsheets, monitoring and evaluation tools
3. Detail oriented and organized with a strong sense of follow-up and completion
4. Experience using time management skills to prioritize/organize and track details and deadlines of multiple projects with varying completion dates
5. Clinical experience that has been either recent, lengthy/and/or diverse
6. Awareness of health care industry trends and strategies
7. Fluency in electronic medical record documentation of clinical care
8. Clinical experience with acute care and ambulatory care operations
9. Knowledge of InterQual criteria
10. Ability to communicate effectively (verbal and written) with individuals internal and external to the organization
11. Conflict Management skills and self-confidence for resolution of outcomes with dissatisfied patients/customers or those for which an outcome was sub-optimal
12. Expert verbal and written communication and presentation skills
13. Strong analytical, organizational, and interpersonal skills
14. Advanced proficiency with Outlook, Microsoft Excel, and Word applications

Responsibilities:

1. Supervise the Grievance and Appeals team to ensure appropriate handling of member appeals and grievances
2. Serve 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 reviews
3. Ensure that all appeals and grievances are investigated thoroughly and resolved in compliance with regulatory requirements
4. Conduct periodic reviews and audits to ensure quality and performance standards are met
5. Develop and maintain records of appeals and grievances for reporting and auditing purposes
6. Prepare and submit documents in response to fair hearings processes and requests; engage internal legal counsel as necessary
7. Prepare and develop reports for, and present to, management related to appeals and grievances and fair hearings
8. Ensure strict adherence to contractual requirements and Medicaid regulations, policies, and procedures
9. Stay informed about changes in health care regulations related to appeals and grievances, and update processes accordingly
10. Prepare and submit required reports to regulatory authorities regarding appeals, grievances and fair hearings activities
11. Provide guidance, mentorship, and training to appeals, grievances, and risk management staff
12. Foster a culture of compliance, quality improvement, and patient-centered care
13. Identify potential conflicts when reviewing and resolving appeals and grievances and escalate such conflicts to appropriate leader for review and resolution
14. May perform other duties in addition to those outlined in this job description

DC RESIDENTS ENCOURAGED TO APPLY

Primary Location:

District of Columbia-Washington

Work Locations:

HSCSN - Vermont Ave, 1101 Vermont Ave NW, Washington, 20005

Job:

Non-Clinical Professional

Organization:

HSC W/Special Needs

Position Status: R (Regular) - FT - Full-Time

Shift: Day

Work Schedule: M-F 9-5

Job Posting:

Sep 3, 2024, 2:47:38 PM

Full-Time Salary Range:

93974.4 - 156603.2

Health 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.