Medical Review & Appeals Director; Hybrid

Medical Review & Appeals Director (Hybrid)

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We are looking for a Director, Medical Review & Appeals for our Government Programs lines of business. The incumbent will ensure alignment with the overall Corporate Strategic Plan through direction and oversight of the Clinical Medical Claims Reviews, Clinical Appeals and Analysis programs and Quality of Care complaints in conjunction with Medical Policy. Ensures that delegated vendor partners are performing as required, in compliance with State and Federal regulatory requirements and accreditation agencies, to ensure members can access the benefits they are entitled to.

Establishes performance metrics to ensure the needs and requirements of our members/enrollees, providers, and regulators are met in accordance with accreditation standards and requirements, CMS, state, Federal and local laws. Plans, directs and evaluates the full scope of services in the department and works closely with leadership, members, providers, vendors, accounts, and other strategic business partners. We are looking for an experienced professional 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 Care First location based on business needs and work activities/deliverables that week.

• Directs all functions related to appeals, grievances, and/or reconsiderations and more for government programs lines of business and manages multiple strategic clinical projects that span organizational boundaries, responsible for management of corporate care cost directives and goals.
• Provides oversight of various clinical and operational vendor partners. Ensures the delegated partner is compliant with all State and Federal regulatory requirements in all jurisdictions within service areas. Ensures that the vendor partner is providing members and accounts with the benefits they are entitled to. Works with other corporate leadership teams to design and execute corrective action plans with vendor partners as appropriate.
• Provides direction and support for Corporate Compliance, including acting as a consultant to the Legal/Sales/Government Affairs/Compliance/Executive Inquiry Teams. Directs professional, clinical, and management support during discovery, depositions, trial, and other legal proceedings. Testifies at depositions, hearings, arbitrations, or trials as expert health care witness. Directs compliance actions, procedures and governance to achieve divisional goals. Leads internal/external audit efforts for Federal and State Regulatory agencies and external Accreditation agencies as it relates to the specific programs within the Division.
• Directs the strategic and the day-to-day activities of the Department, including coaching and guiding individuals and teams in order to implement departmental, divisional, and organizational mission/goals. Recruits, retains and develops a high performing team. Evaluates performance of each team member, generates development plans and sets goals within the context of the corporate policies and procedures. Develops annual goals, and prepares, monitors, and analyzes variances of departmental budgets in order to control and appropriately allocate resources.
• Provides direction for program requirements and reporting under this Division for government programs lines of business, in all jurisdictions.

This position manages people.

Education Level: Bachelor's Degree in Nursing 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.

• RN - Registered Nurse - State Licensure And/or Compact State Licensure.

Experience: 8 years clinical experience in care management. 3 years' experience leading in a managed care or health insurance environment with a focus on Clinical Medical Review and Appeals and Grievances.

• Significant experience with Government programs including Maryland Medicaid, Medicare Advantage and DSNP.

• Knowledge of NCQA requirements of utilization review, Case Management standards and guidelines, appeal rights and responsibilities, and Regulatory requirements at the state and federal level for health care administration and Carrier standards.
• Exceptional professional communication skills are required to persuade, gain cooperation, provide formal presentations to various sized groups, including Sales and Regulatory Agencies, with a proven ability to reach consensus and resolve conflict.
• Knowledge of all types of medical necessity decisions including various places of services and provider types.
• Understanding of the interdependencies between Medical Policy, Clinical Medical…