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 JHHC's 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
Many organizations talk about transforming the future of healthcare, at Johns Hopkins Health Plans, 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, JHHP 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).