MedStar Health
Overview
RN Manager of Grievances & Appeals at MedStar Health. 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 is dedicated to delivering service and operational excellence through continuous improvement in the areas of contribution, competencies, and performance of the Intake, Appeals, Complaints and Grievances team. This role oversees intake, 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. The role utilizes advanced technical knowledge to resolve complex issues, sets objectives, creates policies and procedures, determines approaches, allocates resources and manages 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; ensures appropriate data collection and timely submission. Develops and contributes to department goals; adheres to department policies, procedures, quality and safety standards; ensures compliance with hospital/facility policies and governmental/accreditation regulations. Participates in annual strategic planning objectives; initiates innovative ideas and programs to improve quality while managing medical expense. Ensures retrospective events, appeals, and complaints/grievances timeframes comply with NCQA, EQRO, State of Maryland, District of Columbia, Federal, and other applicable standards. Maintains knowledge of MFC authorization rules for MD and DC and facilitates training to ensure associates, practitioners, facilities and vendors are aware of authorization rules. Acts as clinical liaison with IT and SME for Appeals, Grievances, and Customer Service related to the clinical software system; coordinates system testing, training, and issue resolution. Oversees the selection, orientation, training program, and assignment of new and current associates; maintains up-to-date training manuals. Develops performance standards, evaluates performance, conducts performance management planning and facilitates personnel actions; maintains ongoing communication with subordinates. Participates in multidisciplinary quality and service improvement teams; attends meetings, serves on committees, and represents the department in community outreach as appropriate. Performs other duties as assigned. Minimum qualifications
Education Bachelor's degree in Nursing required Experience 3-4 years Utilization Management experience required 5-7 years diverse clinical experience in a hospital or medical setting required 1-2 years supervisory experience required Additional experience with appeals and grievances preferred Licenses and Certifications RN – Registered Nurse license in Maryland upon hire and DC license prior to start date CCM – Certified Case Manager (CCM) active or certification within 1 year required Knowledge, Skills, and Abilities Excellent verbal and written communication skills. Proficient in Microsoft Word, Excel, and PowerPoint.
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RN Manager of Grievances & Appeals at MedStar Health. 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 is dedicated to delivering service and operational excellence through continuous improvement in the areas of contribution, competencies, and performance of the Intake, Appeals, Complaints and Grievances team. This role oversees intake, 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. The role utilizes advanced technical knowledge to resolve complex issues, sets objectives, creates policies and procedures, determines approaches, allocates resources and manages 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; ensures appropriate data collection and timely submission. Develops and contributes to department goals; adheres to department policies, procedures, quality and safety standards; ensures compliance with hospital/facility policies and governmental/accreditation regulations. Participates in annual strategic planning objectives; initiates innovative ideas and programs to improve quality while managing medical expense. Ensures retrospective events, appeals, and complaints/grievances timeframes comply with NCQA, EQRO, State of Maryland, District of Columbia, Federal, and other applicable standards. Maintains knowledge of MFC authorization rules for MD and DC and facilitates training to ensure associates, practitioners, facilities and vendors are aware of authorization rules. Acts as clinical liaison with IT and SME for Appeals, Grievances, and Customer Service related to the clinical software system; coordinates system testing, training, and issue resolution. Oversees the selection, orientation, training program, and assignment of new and current associates; maintains up-to-date training manuals. Develops performance standards, evaluates performance, conducts performance management planning and facilitates personnel actions; maintains ongoing communication with subordinates. Participates in multidisciplinary quality and service improvement teams; attends meetings, serves on committees, and represents the department in community outreach as appropriate. Performs other duties as assigned. Minimum qualifications
Education Bachelor's degree in Nursing required Experience 3-4 years Utilization Management experience required 5-7 years diverse clinical experience in a hospital or medical setting required 1-2 years supervisory experience required Additional experience with appeals and grievances preferred Licenses and Certifications RN – Registered Nurse license in Maryland upon hire and DC license prior to start date CCM – Certified Case Manager (CCM) active or certification within 1 year required Knowledge, Skills, and Abilities Excellent verbal and written communication skills. Proficient in Microsoft Word, Excel, and PowerPoint.
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