Johns Hopkins Medicine Appeals Director in Glen Burnie, Maryland
Johns Hopkins Health Care,
Glen Burnie, MD
Requisition # 155746
Full Time (40 hours)
Weekend Work Not Required
Johns Hopkins Health System employs more than 20,000 people annually. Upon joining Johns Hopkins Health System, you become part of a diverse organization dedicated to its patients, their families, and the community we serve, as well as to our employees. Career opportunities are available in academic and community hospital settings, home care services, physician practices, international affiliate locations and in the health insurance industry. If you share in our vision, mission and values and also have exceptional customer service and technical skills, we invite you to join those who are leaders and innovators in the healthcare field.
Reports to the Assistant Vice President, Health Services serves as the primary contact/liaison for the Appeals Department. Responsibility includes oversight of the Appeals Department managing the BPO relationship supporting operations and other Medicare Advantage functions. This position oversees and manages pended claims reconciliation process and submission of appeals from for providers and members covering all lines of business under Johns Hopkins Healthcare. Duties include ongoing monitoring and tracking of department inventory; maintaining adequate staffing, ensuring adequate staff training and ongoing education; ensuring regulatory requirements are met.
Also establishes performance metrics for both the vendor and internal functions to ensure excellent service delivery to our members and providers. Also ensures JHHC maintains the highest possible standards of quality and operational compliance in line with JHHC’s business direction, regulatory and CMS STARS rating measures.
A. Education :
Master of Science in Nursing (MSN)
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 one year of management responsibilities. Comprehensive knowledge of DOL, COMAR and DOD regulations related to benefits and appeals. 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.
D. Required Licensure, Certification, Etc.:
Active Maryland RN licensure required, if hired with a degree in nursing.
E. Work Experience
Work requires a minimum of five years experience which includes progressive management responsibilities in the areas of managed care, utilization management, quality management or claims management.
F. Machines, Tools, Equipment:
Must be able to operate general office and communications equipment. Must be computer literate.
Johns Hopkins Health System and its affiliates are Equal Opportunity/Affirmative Action employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sexual orientation, gender identity, sex, age, national origin, disability, protected veteran status, and or any other status protected by federal, state, or local law.