Minimum Education

• Knowledge of health care evaluation methodology, medical terminology, and regulations

• Strong organizational, analytical, and data management skills, including word processing, spreadsheets, monitoring and evaluation tools

• Detail oriented and organized with a strong sense of follow-up and completion.

• Experience using time management skills to prioritize/organize and track details and deadlines of multiple projects with varying completion dates.

• Clinical experience that has been either recent, lengthy/and/or diverse

• Awareness of health care industry trends and strategies

• Fluency in electronic medical record documentation of clinical care

• Clinical experience with acute care and ambulatory care operations

• Knowledge of InterQual criteria

• Ability to communicate effectively (verbal and written) with individuals internal and external to the organization.

• Conflict Management skills and self-confidence for resolution of outcomes with dissatisfied patients/customers or those for which an outcome was sub-optimal

• Expert verbal and written communication and presentation skills

• Strong analytical, organizational, and interpersonal skills.

• Advanced proficiency with Outlook, Microsoft Excel, and Word applications

• Supervise the Grievance and Appeals team to ensure appropriate handling of member appeals and grievances.

• Serves as the organization’s subject matter expert on the Chart Retrieval & Clinical Review platform, including interactions with and impacts on adjacent services. Maintains appropriate documentation to meet regulatory reviews.

• Ensure that all appeals and grievances are investigated thoroughly and resolved in compliance with regulatory requirements.

• Conduct periodic reviews and audits to ensure quality and performance standards are met.

• Develop and maintain records of appeals and grievances for reporting and auditing purposes.

• Prepare and submit documents in response to fair hearings processes and requests; engage internal legal counsel as necessary.

• Prepare and develop reports for, and present to, management related to appeals and grievances and fair hearings.

• Ensure strict adherence to contractual requirements and Medicaid regulations, policies, and procedures.

• Stay informed about changes in health care regulations related to appeals and grievances, and update processes accordingly.

• Prepare and submit required reports to regulatory authorities regarding appeals, grievances and fair hearings activities.

• Provide guidance, mentorship, and training to appeals, grievances, and risk management staff.

• Foster a culture of compliance, quality improvement, and patient-centered care.

• Identifies potential conflicts when reviewing and resolving appeals and grievances and escalates such conflicts to appropriate leader for review and resolution.

• May perform other duties in addition to those outlined in this job description.

DC RESIDENTS ENCOURAGED TO APPLY