- 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.
-
Johns Hopkins Health Plans Hanover, United StatesJob 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 th ...
-
Director of Appeals, Complaints, and Grievances
2 weeks ago
Johns Hopkins Medicine Hanover, United StatesShare 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 Ap ...
-
Johns Hopkins Health Plans Hanover, United StatesJob 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 th ...
-
Director of Appeals, Complaints, and Grievances
3 weeks ago
Johns Hopkins Health Plans Hanover, United States**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 includin ...
-
Customer Service Representative
1 week ago
The Reserves Network Inc Hanover, United StatesJob Description · Job DescriptionYour New Organization: Looking to build your career in an exciting industry and a growing world class organization? They are the largest pest control company in the world, and they are looking to add a customer service representative to their team ...
-
Human Resources Generalist
2 weeks ago
Latitude Inc Hanover, United StatesJob Title: Human Resources Generalist · Schedule: (Hybrid:1-2 days remote, otherwise on-site) · Overview: · As a Human Resources Generalist, you will be responsible for providing support in various HR functions, including recruitment, employee relations, performance management ...
-
Unit Manager
1 week ago
August Healthcare at Wilmington Wilmington, United StatesPurpose of Your Job Position · The primary purpose of your position is to supervise the day-to-day nursing activities of the Facility during your tour of duty. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations th ...
-
Enrollment Specialist
19 hours ago
Vaya Health Wilmington, United StatesLOCATION: Remote –This is a home based, virtual position that operates on US Eastern Standard Time within the hours of 8:30am-5:00pm. Vaya Health welcomes applications from NC, SC, GA, TN, VA, MD, and FL. · GENERAL STATEMENT OF JOB · This position will ensure that all client da ...
-
HR Manager, Hotel DUPONT
1 week ago
Wave Resort Wilmington, United States** HR Manager, Hotel DUPONT** · **Job Category****:** Admin & General **Requisition Number****:** HRMAN07998 Showing 1 location **Job Details** · **Description** · Job Summary · Assists in the development, implementation and administration of all human resource functions, inc ...
-
Director | People Culture | HOTEL DU PONT
3 weeks ago
Wave Resort Wilmington, United States** Director | People Culture | HOTEL DU PONT** · **Job Category****:** Admin & General **Requisition Number****:** DIREC009387 Showing 1 location **Job Details** · **Description** · Job Summary · Directs and ensures the efficient administration and management of the human res ...
-
Patient Relations Rep
2 weeks ago
UPMC Hanover, United StatesJoin our team of Life Changers · UPMC is hiring a **Full-Time, Patient Relations Representative** to support the office in **Hanover.** · **Shift is Monday-Friday 8:00am-4:30pm** · **No weekends or holidays required** · This position requires some travel to other locations which ...
-
Activities Assistant
3 weeks ago
August Healthcare at Wilmington Wilmington, United StatesJob Description · Purpose of Your Job Position · The primary purpose of your position is to assist in planning, implementation, and evaluation of recreational, social, intellectual, emotional, and spiritual programs, in accordance with the resident's assessment and care plan, a ...
Director of Appeals, Complaints, and Grievances - Hanover, United States - Johns Hopkins Health Plans
Description
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 JHHCs 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
