Medical Review & Appeals Director (Hybrid)

Resp & Qualifications

PURPOSE:

Ensures alignment with the overall Corporate Strategic Plan through direction of the Clinical Medical Claims Review, Medical Underwriting, Medical Policy, Clinical Appeals and Analysis programs and Quality of Care Complaint Unit. May lead our Commercial team and our Government Programs (Medicaid and Medicare) team. 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, 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 people 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:

• Directs the Medical Review and Appeals units and manages multiple strategic clinical projects that span organizational boundaries, responsible for management of corporate care cost directives and goals.

• Oversees the research, development, and coordination of the distribution and dissemination of medical policies in support of corporate philosophy, provider and member contracts, and accepted standards of medical practice.

• 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 all lines of business, all jurisdictions.

SUPERVISORY RESPONSIBILITY:

This position manages people.

QUALIFICATIONS:

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.

Licenses/Certifications Upon Hire Required:

• 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.

Preferred Qualifications:

• Applicants with specific experience in Medicare and / or Medicaid appeals are especially welcome.

Knowledge, Skills and Abilities (KSAs)

• 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 Review and Appeals and Grievances.

• Ability to mentor and coach associates to accomplish goals, provide objective evaluation of associate performance, and implement strategies to improve individual and team-based performance as needed.

• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

Salary Range: $149,120 - $276,804

Salary Range Disclaimer

The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).

Department

Core Clinical Operations Administration

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.

Where To Apply

Please visit our website to apply: ~~~/careers

Federal Disc/Physical Demand

Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

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

#LI-SS1

REQNUMBER: 19719