Talent.com
Clinical Appeals Supervisor (Hybrid)
Clinical Appeals Supervisor (Hybrid)Maryland Staffing • Baltimore, MD, US
Clinical Appeals Supervisor (Hybrid)

Clinical Appeals Supervisor (Hybrid)

Maryland Staffing • Baltimore, MD, US
5 days ago
Job type
  • Full-time
Job description

Clinical Appeals Supervisor

The Clinical Appeals Supervisor directs and coordinates the accurate implementation of the clinical appeal process for members and providers who appeal on behalf of members for Government Programs lines of business. Develops, evaluates and oversees the implementation of policies and procedures that result in quality resolution of member and provider disputes regarding adverse and adverse coverage determinations in accordance with Federal and State mandates. Directs the activities and serves as a resource for associates within the Appeals and Grievances Department for Government Programs.

We are looking for an experienced clinical leader in the greater Baltimore metropolitan area who is willing and able to work in a hybrid model. The incumbent will be expected to work a portion of their week from home and a portion of their week at a CareFirst location based on business needs and work activities / deliverables that week.

Essential Functions :

  • Provides direct supervision for the activities of assigned staff, ensuring appropriate and complete resolution of appeals and reconsiderations, including regulatory complaints and external review requests.
  • Coordinates and / or conducts research, summarizes medical documentation and oversees the chronological presentation of plan handling to respond to regulatory complaints and to assist the Legal Department.
  • Responsible for development and oversight of the orientation and training of new and current associates, and assessment of department training needs.
  • Responsible for identification, research and coordinating a comprehensive response to problems, issues or concerns that have a cross functional impact throughout the company.
  • Develops informative, educational and training presentations for internal and external stakeholders.

Qualifications :

  • Education Level : High School Diploma or GED OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.
  • Licenses / Certifications : RN - Registered Nurse - State Licensure And / or Compact State Licensure Upon Hire Required. CCM - Certified Case Manager Upon Hire Preferred. LNCC - Legal Nurse Consultant Certified Upon Hire Preferred.
  • Experience : 5 years medical-surgical or similar clinical experience OR 5 years' experience in Medical Review, Utilization Management or Case Management at CareFirst BlueCross BlueShield, or similar Managed Care organization or hospital.

    • Salary Range : $78,696 - $162,311

    Equal Employment Opportunity : CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

    Physical Demands : The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.

    Sponsorship in US : Must be eligible to work in the U.S. without Sponsorship

    Create a job alert for this search

    Clinical Supervisor • Baltimore, MD, US