Current jobs related to Director of Appeals, Complaints, and Grievances - Hanover - Johns Hopkins Medicine

  • Clinical Appeals Specialist

    2 weeks ago

    Hanover Hills, Maryland, United States Johns Hopkins Health System Full time

    About the RoleWe are seeking a highly skilled Clinical Appeals Specialist to join our team at Johns Hopkins Health System. As a Clinical Appeals Specialist, you will play a critical role in ensuring that our members receive timely and accurate decisions on their appeals.Key ResponsibilitiesReview and analyze medical records to determine the appropriateness...

  • Appeals Nurse Analyst

    3 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. Johns Hopkins Health Plans (JHHP) is the managed care and health services business of Johns Hopkins Medicine. JHHP is a $3B business...

  • Appeals Nurse Analyst

    1 month ago

    Hanover, United States Johns Hopkins Medicine Full time

    This position is eligible for remote work, if you live in one of the following states: Maryland, Virginia, Delaware, Pennsylvania, Florida, or Washington DC. 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...

  • Inpatient Care Physician

    3 weeks ago

    Hanover, Illinois, United States Recruitment Reimagined Full time

    Position Overview:We are looking for a dedicated and quality-driven physician leader to become a part of our expanding team of hospitalists.Leadership Role:The ideal candidate will possess a collaborative leadership approach, exemplifying and promoting excellence in clinical practice, patient interactions, and professional conduct.Team Structure:The...

  • Director of Food

    4 weeks ago

    Hanover, United States Hanover Inn at Dartmouth College Full time

    OverviewHanover Inn, a prestigious and historic hotel known for its exceptional service and luxurious ambiance, is seeking an experienced Director of Food & Beverage. We are dedicated to providing unparalleled guest experiences and are looking for a dynamic leader to elevate our Food & Beverage operations.The objectives of the Director of Food & Beverage are...

  • Human Resources Director

    3 weeks ago

    Hanover Hills, Maryland, United States Allegis Global Solutions Full time

    Job Description**About Allegis Global Solutions**Allegis Global Solutions is a leading provider of workforce solutions, helping companies around the world transform their people into a competitive advantage. Our mission is to create real, measurable impact that moves needles.**Job Summary**We are seeking a highly skilled Human Resources Manager to join our...

  • Wellness Director

    3 weeks ago

    Hanover, United States Volante of Hanover Full time

    This position is located in Hanover, MN.Make sure to apply quickly in order to maximise your chances of being considered for an interview Read the complete job description below.We are looking for a Wellness Director to join our team! You will play a crucial role in shaping the health and happiness of our residents while enjoying a fulfilling and rewarding...

  • Director of Food and Beverage Operations

    3 weeks ago

    Hanover, New Hampshire, United States Hanover Inn at Dartmouth College Full time

    Job SummaryHanover Inn at Dartmouth College is seeking an experienced and dynamic leader to join our team as the Director of Food and Beverage Operations. As a key member of our hotel management team, you will be responsible for driving the success of our Food and Beverage Department and delivering exceptional guest experiences.Key ResponsibilitiesDevelop...

  • Factory Store Associate

    3 weeks ago

    Hanover, Pennsylvania, United States Campbell Soup Company Full time

    Job SummaryWe are seeking a highly motivated and customer-focused Factory Store Associate to join our team at the Campbell Soup Company. As a Factory Store Associate, you will play a critical role in providing exceptional customer service, maintaining a clean and organized store environment, and supporting the sales floor team.Key ResponsibilitiesAssist...

  • Assistant Director, Early Childhood Education/Preschool

    3 months ago

    Hanover, United States The Goddard School of Hanover, MD Full time

    Job DescriptionJob DescriptionBenefits:Competitive salaryDental insuranceHealth insurancePaid time offParental leaveTraining & developmentVision insurance The Goddard School located in Hanover is looking for a motivated, self-starter for an Assistant Director position at our School. The ideal candidate must have strong leadership skills, excellent...

  • Business Analyst

    1 month 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...

  • Customer Service Representative

    6 days ago

    Hanover, Pennsylvania, United States raymour and flanigan Full time

    About UsAt Raymour and Flanigan, we believe that our associates are the key to delivering exceptional customer experiences. We're committed to creating a workplace where everyone feels valued, respected, and empowered to excel.Job SummaryWe're seeking a highly skilled Customer Service Representative to join our team. As a Customer Service Representative, you...

  • Front Desk Coordinator

    3 weeks ago

    Hanover, Pennsylvania, United States Pennsylvania Cancer Specialists and Research Institute Full time

    Job Description:At Pennsylvania Cancer Specialists and Research Institute, we are seeking a highly motivated and detail-oriented Front Desk Coordinator to join our team. As a key member of our patient services team, you will play a vital role in ensuring the smooth operation of our front desk and providing exceptional patient care.Key...

  • Animal Control Specialist

    3 weeks ago

    Hanover, Pennsylvania, United States County of Jackson Florida Full time

    About the RoleThe County of Jackson Florida is seeking a highly motivated and detail-oriented individual to fill the position of Animal Control Officer. As a key member of our team, you will play a vital role in enforcing animal control ordinances and ensuring the welfare of animals in our community.Key ResponsibilitiesEnforce animal control ordinances and...

  • Human Resources Manager

    3 months ago

    Hanover, United States Allegis Global Solutions Full time

    Job DescriptionJob DescriptionCompany DescriptionWorking at Allegis Global Solutions (AGS) is more than just a job. It’s a career. It’s a community of people who invest in your development and empower you to blaze your own trail. Each of us is here to create real, measurable impact that moves needles. We operate beyond "roles" or "jobs" to realize the...

  • Customer Service Representative

    3 weeks ago

    Hanover, Pennsylvania, United States Rite Aid of Pennsylvania Inc Full time

    Job Summary:As a Service Associate at Rite Aid of Pennsylvania Inc, you will play a vital role in delivering exceptional customer service and contributing to the success of our retail operations. Your primary responsibility will be to provide a positive shopping experience for our customers, ensuring their needs are met and exceeded.Key Responsibilities:•...

  • Fleet Operations Supervisor

    4 weeks ago

    Hanover, Virginia, United States County of Hanover Virginia Full time

    Position Overview:This role is a professional opportunity focused on overseeing the transportation initiatives within the organization. The incumbent will engage in intricate responsibilities related to managing the transportation program for the Community Service Boards (CSBs) and will also supervise the fleet for the Developmental Disabilities division.Key...

  • Executive Chef and Operations Manager

    3 weeks ago

    Hanover, New Hampshire, United States Hanover Inn at Dartmouth College Full time

    Job SummaryHanover Inn at Dartmouth College is seeking an experienced and dynamic leader to join our team as the Director of Food and Beverage Operations. As a key member of our hotel management team, you will be responsible for driving the success of our Food and Beverage Department and delivering exceptional guest experiences.Key ResponsibilitiesDevelop...

  • Food and Beverage Department Head

    3 weeks ago

    Hanover, New Hampshire, United States Hanover Inn at Dartmouth College Full time

    Job SummaryHanover Inn at Dartmouth College is seeking an experienced and dynamic leader to join our team as the Director of Food and Beverage Operations. As a key member of our hotel management team, you will be responsible for driving the success of our Food and Beverage Department and delivering exceptional guest experiences.Key ResponsibilitiesDevelop...

  • Patient Care Technician

    4 months ago

    Hanover, United States University of Pittsburgh Medical Center Full time

    Title and starting pay rate of this position may vary based on years of experience. Responsibilities: * Provides patient care including assisting with patient procedures and activities of daily living. Assists with physical, respiratory and cardiopulmonary therapies. Provides feedback to the RN regarding patient care and reports changes in patient...

Director of Appeals, Complaints, and Grievances

4 months ago

Hanover, United States Johns Hopkins Medicine Full time

Share 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 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.

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. 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.

Please note: US citizenship is required for this position as it falls under the terms of a government contract (to ensure compliance with DODPSP).

#J-18808-Ljbffr