Job Details
Job Summary
Reporting to the Chief Medical Officer, the Director of Complaints, Grievances, and Appeals (CG&A) is responsible for directing CG&A operations, providing leadership and oversight for all lines of business.
The Director will oversee key CG&A functions including the processing of member appeals, provider appeals, and payment disputes. In addition, they will ensure compliance with State regulations, clinical appropriateness of determinations, and quality of customer service. The Director will also oversee and maintain relationships with outside physician reviewers. Additional duties include ongoing monitoring and tracking of department inventory, maintaining adequate staffing, ensuring adequate staff training and ongoing education, and meeting regulatory requirements.
The Director also establishes performance metrics for both the vendor and internal functions to ensure excellent service delivery to our members and providers. They ensure JHHC maintains the highest possible standards of quality and operational compliance in line with JHHC s strategic goals, accreditation, regulatory, and CMS STARS rating measures. The Director will serve as primary contact for state regulatory agencies and consumer advocacy agencies regarding member CG&A issues.
Qualifications
- Master of Science in health care related field strongly preferred. Bachelors and equivalent experience required.
- 7-10+ years of progressively responsible related experience including 3-5 years of management experience.
- Active Maryland RN licensure required, if hired with a degree in nursing.
- Work requires knowledge of the health field and managed care case management/utilization management processes as acquired during five years of related experience with at least five years of management responsibilities. Comprehensive knowledge of CMS, DOL, COMAR and DOD regulations related to benefits, appeals, complaints, and grievances. In-depth knowledge of data acquisition, data analysis, reporting, and use of data to make decisions is necessary.