Director of Appeals, Complaints, and Grievances
3 weeks ago
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.
-
Director of Appeals, Complaints, and Grievances
2 weeks ago
Hanover, United States Johns Hopkins Health Plans Full timeJob SummaryReporting 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,...
-
Director of Appeals, Complaints, and Grievances
3 weeks ago
Hanover, United States Johns Hopkins Health Plans Full timeJob SummaryReporting 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,...
-
Director of Appeals, Complaints, and Grievances
13 hours ago
Hanover, United States Johns Hopkins Medicine Full timeShare This Page Job Details Requisition #: 639299 Location: Johns Hopkins Health Plans, Hanover, MD 21076 Category: Leadership Schedule: Day Shift 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...
-
Director of Appeals, Complaints, and Grievances
2 weeks ago
Hanover, United States Johns Hopkins Medicine Full timeShare This Page Job Details Requisition #: 639299 Location: Johns Hopkins Health Plans, Hanover, MD 21076 Category: Leadership Schedule: Day Shift 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...
-
Patient Relations Rep
7 days ago
Hanover, United States University of Pittsburgh Medical Center Full timeJoin our team of Life Changers! UPMC is hiring a Full-Time, Patient Relations Representative to support the office in Hanover. Excellent benefits, a pleasant work environment, and friendly team are just a few of our perks. Apply today! Shift is Monday-Friday 8:00am-4:30pm No weekends or holidays required This position requires some travel to other...
-
Patient Relations Rep
7 days ago
Hanover, United States UPMC Full timeJoin our team of Life Changers! UPMC is hiring a Full-Time, Patient Relations Representative to support the office in Hanover. Excellent benefits, a pleasant work environment, and friendly team are just a few of our perks. Apply today! Shift is Monday-Friday 8:00am-4:30pm No weekends or holidays required This position requires some travel to other...
-
Patient Relations Rep
7 days ago
Hanover, United States UPMC Life Changing Medicine Full timeJoin our team of Life Changers!UPMC is hiring a Full-Time, Patient Relations Representative to support the office in Hanover. Excellent benefits, a pleasant work environment, and friendly team are just a few of our perks. Apply today! Shift is Monday-Friday 8:00am-4:30pmNo weekends or holidays requiredThis position requires some travel to other locations...
-
Executive Director
1 day ago
Hanover, United States Benchmark Senior Living Full timeJob Description Benchmark Senior Living at Hanover is seeking an Executive Director! Joining the Benchmark Senior Living team means putting your passion to work. Our associates feel a sense of belonging with the care that they provide, empowered by the open and reliable team that surrounds them. Our diverse and skilled workforce takes immense pride in a...
-
Executive Director of Compliance
1 week ago
Hanover, United States Johns Hopkins Health Plans Full timeSummary The Executive Director of Corporate Compliance and Regulatory Affairs (“Exec. Director”) at Johns Hopkins Health Plans (JHHP) reports to the Johns Hopkins Health System (JHHS) Chief Compliance Officer (and reports via a matrix relationship to the President of JHHP). The Exec. Director is responsible for the development, implementation,...
-
Director Sales Engineering
2 weeks ago
Hanover, United States Employbridge Full timeThe Sales Engineering Director is the head of our sales organization and will be responsible for driving profitable growth, building, and maintaining relationships with key clients, developing the Sales and Customer Service Team, and executing sales strategies.Job Duties and responsibilities:• Develop and execute strategic plans to grow profitably.•...
-
Director Sales Engineering
4 weeks ago
Hanover, United States Employbridge Full timeThe Sales Engineering Director is the head of our sales organization and will be responsible for driving profitable growth, building, and maintaining relationships with key clients, developing the Sales and Customer Service Team, and executing sales strategies.Job Duties and responsibilities:• Develop and execute strategic plans to grow profitably.•...
-
Executive Director of Compliance
1 month ago
Hanover, United States Johns Hopkins Medicine Full timeShare This Page Job Details Requisition #: 630166 Location: Johns Hopkins Health Plans, Hanover, MD 21076 Category: Leadership Schedule: Day Shift Summary The Executive Director of Corporate Compliance and Regulatory Affairs ("Exec. Director") at Johns Hopkins Health Plans (JHHP) reports to the Johns Hopkins Health System (JHHS) Chief Compliance Officer (and...
-
Hanover, United States National Collegiate Athletic Association Full timeThe Associate Athletics Director for Sport Administration reports to the Executive Associate Athletics Director for Administration and will assist in providing day-to-day support and leadership to the Sport Administration team, consisting of 10+ primary and secondary sport administrators. This role assists and supports the strategic leadership and...
-
Hanover, United States Elevance Health Full timeJob Family: QLT > Quality Mgmt - Type: Full time - Date Posted: Apr 25, 2024 - Anticipated End Date: May 31, 2024 - Reference: JR102453 **Description**: **A proud member of the Elevance Health family of companies, Carelon Behavioral Health, formerly Beacon Health Options, offers superior clinical mental health and substance use disorder management, a...
-
Associate Medical Director
22 hours ago
Hanover, United States Elevance Health Full timeElevance Health Associate Medical Director - Neurosurgery Hanover , Maryland Apply Now Clinical Operations Associate Medical Director Carelon Insights/Carelon Medical Benefits Management A proud member of the Elevance Health family of companies, Carelon Medical Benefits Management, formerly AIM Specialty Health, is a benefit-management leader in Illinois....
-
Director of Quality Assurance, Manufacturing
2 days ago
Hanover, United States Utz Brands, Inc. Full timeJob Description Utz Quality Foods is seeking a Director of Quality Assurance, Manufacturing. The Director of Quality Assurance, Manufacturing is responsible to organize, direct, control and evaluate the operations of the Quality Assurance and Food Safety (QAFS) systems across internal manufacturing facilities. Key ResponsibilitiesCoaches, develops, and...
-
Director of Medicaid and Commercial Quality
4 weeks ago
Hanover, United States Johns Hopkins Health Plans Full time**Job Summary** Under the direction of the Associate Chief Medical Officer, Quality & Transformation, this execution-focused position of the Quality Performance Director, for Medicaid, USFHP & EHP will support quality performance management for the Medicaid line of business, Priority Partners Managed Care organization (PPMCO), TRICARE Prime (USFHP), and...
-
Hanover, United States Johns Hopkins Health Plans Full timeJob SummaryUnder the direction of the Associate Chief Medical Officer, Quality & Transformation, this execution-focused position of the Quality Performance Director, for Medicaid, USFHP & EHP will support quality performance management for the Medicaid line of business, Priority Partners Managed Care organization (PPMCO), TRICARE Prime (USFHP), and...
-
Hanover, United States Johns Hopkins Health Plans Full timeJob SummaryUnder the direction of the Associate Chief Medical Officer, Quality & Transformation, this execution-focused position of the Quality Performance Director, for Medicaid, USFHP & EHP will support quality performance management for the Medicaid line of business, Priority Partners Managed Care organization (PPMCO), TRICARE Prime (USFHP), and...
-
Hanover, United States Johns Hopkins Health System Full timeJob SummaryUnder the direction of the Associate Chief Medical Officer, Quality & Transformation, this execution-focused position of the Quality Performance Director, for Medicaid, USFHP & EHP will support quality performance management for the Medicaid line of business, Priority Partners Managed Care organization (PPMCO), TRICARE Prime (USFHP), and...
