Clinical Appeals Manager

7 days ago


New York, New York, United States MJHS Full time
Clinical Appeals Manager Job Description

The challenges of affordable healthcare create new opportunities for growth and development. At MJHS, our goal is to expand services in response to our patients' and members' needs. We are seeking a Clinical Appeals Manager to lead our clinical review operations and ensure that all tasks are handled efficiently and effectively.

As a Clinical Appeals Manager, you will be responsible for managing and processing clinical appeals, grievances, and quality of care concerns that conform to regulatory requirements. You will collaborate with other A&G Management staff to ensure that all tasks are handled and that key performance indicators are accurately collected and reported.

Key Responsibilities:

  • Collect and report on key performance indicators for all clinical review processes
  • Capture reporting elements for analysis and offer recommendations for improvement
  • Assist with leading ongoing quality improvement efforts
  • Monitor outcomes of Quality of Care concerns as identified through appeal and grievance processing
  • Work closely with the Director of A&G, Delegated Vendor Unit, Service Operations, and other Departments for continuous improvement


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