Clinical Appeals Nursing Supervisor

2 weeks ago

Hanover, United States Johns Hopkins Medicine Full time

Johns Hopkins Health Plans is a leader in provider-sponsored health plans. If you are interested in improving how healthcare is delivered, and have a passion to be at the forefront of change, JHHP is the place to call home. YOU belong here.

What awaits you:

  • Work-life balance - This is a hybrid role requiring you to work 1 day per week in the Hanover, MD office
  • Medical, Dental, and Vision Insurance.
  • 403B Savings Plan w/employer contribution.
  • Paid Time off & Paid holidays.
  • Employee and Dependent Tuition assistance benefits.
  • Health and wellness programs and MORE

Who you are:

As the Clinical Appeals Nursing Supervisor for Johns Hopkins Health Plans, you are responsible for the daily operations of the Clinical Appeals Team. In addition, applying your clinical expertise and knowledge of our Medical Policy and InterQual criteria, you assist your team in determining the outcome of requested appeals.

As the Supervisor, you’ll:

  • Be responsible for the daily operations of the Clinical Appeals Team to include but not limited to:
    • Training
    • Auditing
    • Evaluations
    • Managing daily assignments
    • Researching and responding to clinical questions as it relates to appeal process
  • Be responsible for research and triage of appeals.
  • Work with all staff to ensure compliance with all applicable regulatory and accreditation standards and mandates.
  • Perform internal quality improvement activities. Analyze quality audit data to identify trends and opportunities to improve service delivery.
  • Assist the team with occasional weekend coverage as needed to support the lines of business.

What you’ll bring:

  • 2+ years’ experience in Managed Care Appeals and/or Utilization Review experience
  • 5+ years’ total experience which includes progressive responsibilities in the areas of supervision of staff, managed care, appeals, utilization management, quality management or claims management.
  • Knowledge of health insurance standard of practice as evidenced by working in a payer environment whether case management, utilization management, appeals, or claims processing. Participation in quality improvement activities would be beneficial.
  • RN license from Maryland (or Compact state) is required

Who we are:

Johns Hopkins Health Plans (JHHP) is the managed care and health services business of Johns Hopkins Medicine. JHHP is a $3B business serving over 500,000 active members with lines of business in Medicaid, Medicare, commercial, military health, health solutions, and venture investments. JHHP is a leader in provider-sponsored health plans and is poised for future growth.

Many organizations talk about transforming the future of healthcare, at Johns Hopkins Health Plans, we are setting the pace for change within the healthcare industry. We develop innovative, analytics-driven health programs in collaboration with provider partners to drive improved quality and better health outcomes for our members and the communities we serve.

Johns Hopkins Health System and its affiliates are drug-free workplace employers.

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