Manager Clinical Appeals

Who you are:

As the Manager of Clinical Appeals you will oversee and manage the clinical team that handles the clinical appeals processes from providers and for members covering all lines of business under Johns Hopkins HealthCare.

What you’ll do:

• Ongoing monitoring and tracking of department inventory
• Responsible for hiring and training clinical staff (Registered Nurses)
• Represent Johns Hopkins HealthCare at external hearings related to clinical appeals decisions
• Vendor reconciliations
• Developing and updating policies for clinical staff
• Utilizes defined policies and procedures to ensure consistent application of appeals regulations and criteria
• Responsible for adequate scheduling and coverage (to occasionally include leadership staff) of the appeals area (to include rotation of weekends & holidays)
• Provides guidance and direction to other departmental management and staff related to clinical appeals

What you’ll bring:

• 5+ years’ experience in the areas of clinical appeals, managed care, utilization management, quality management or claims management
  • 1+ years’ leadership experience in one of these functional areas
• Comprehensive knowledge of DOL, COMAR, Medicare Advantage, and DOD regulations related to benefits and appeals.
• Must be able to use and understand medical records, UB92 forms and HCFA 1500 forms, benefits and regulations related to appeals.
• Knowledge of CPT, ICD-10, and HCPCS highly preferred
• In-depth knowledge of data acquisition, data analysis, reporting, and use of data to make decisions is necessary.
• Work requires a high level of interpersonal skills to effectively interact with all levels of staff, clients, regulatory bodies, attorneys, etc.
• Work requires the ability to work independently, to assess situations and respond appropriately, make independent decisions and the ability to evaluate and initiate and implement policy and procedures.
• Ability to assess workflow processes for efficiency and rationality and implement changes to make processes more efficient and cost-effective.
• Work requires excellent communication and writing skills.
• Work requires professional level of knowledge in health field as acquired through a Bachelor’s degree. Master’s degree or degree in Nursing is preferred.
• Active Maryland RN licensure required, if hired with a degree in nursing.

Who we are:

Johns Hopkins HealthCare (JHHC) is the managed care and health services business of Johns Hopkins Medicine. JHHC is a $3B business serving over 500,000 active members with lines of business in Medicaid, Medicare, commercial, military health, health solutions, and venture investments. JHHC is a leader in provider-sponsored health plans and is poised for future growth.

Many organizations talk about transforming the future of healthcare, at Johns Hopkins HealthCare, 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, JHHC 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).

This position is eligible for remote work.

Johns Hopkins Health System and its affiliates are drug-free workplace employers.