PN-10018066 HSCSN OAG Coordinator

1101 Vermont Ave NW Suite 1200 Washington, DC 20005

 

Kids Are Our Everything.

 

Department

10513 HSCSN - Administration

 

Pay Range

$48,672.00 - $81,120.00

 

This position manages the day-to-day operations of the Appeals and Grievances operations for our Medicaid Health Plan - HSCSN. Assures that the department is compliant with all regulatory requirements, manages turnaround times, submit reports to the executive leadership team, develops strategies to improve processes. This position has three direct reports and is a hybrid telework position.

 

Qualifications - External

Minimum Education

Bachelor’s degree  - required

Bachelors Degree in healthcare related field - preferred

Master's Degree- preferred                                                 

Minimum Work Experience       

5 years Appeals and Grievances experience - required                              

3 years Managed Care experience - required                                

3 years Acute, Med-Surg, or Ambulatory care experience in a clinical role - preferred                                       

Required Licenses

Registered Nurse DC preferred/Compact - preferred

Required Skills/Knowledge

•            Knowledge of health care evaluation methodology, medical terminology, and regulations

•            Strong organizational, analytical, and data management skills, including word processing, spreadsheets, monitoring and evaluation tools

•            Detail oriented and organized with a strong sense of follow-up and completion.

•            Experience using time management skills to prioritize/organize and track details and deadlines of multiple projects with varying completion dates.

•            Clinical experience that has been either recent, lengthy/and/or diverse

•            Awareness of health care industry trends and strategies

•            Fluency in electronic medical record documentation of clinical care

•            Clinical experience with acute care and ambulatory care operations

•            Knowledge of InterQual criteria

•            Ability to communicate effectively (verbal and written) with individuals internal and external to the organization.

•            Conflict Management skills and self-confidence for resolution of outcomes with dissatisfied patients/customers or those for which an outcome was sub-optimal

•            Expert verbal and written communication and presentation skills

•            Strong analytical, organizational, and interpersonal skills.

•            Advanced proficiency with Outlook, Microsoft Excel, and Word applications

•            Supervise the Grievance and Appeals team to ensure appropriate handling of member appeals and grievances.

•            Serves as the organization’s subject matter expert on the Chart Retrieval & Clinical Review platform, including interactions with and impacts on adjacent services. Maintains appropriate documentation to meet regulatory reviews.

•            Ensure that all appeals and grievances are investigated thoroughly and resolved in compliance with regulatory requirements.

•            Conduct periodic reviews and audits to ensure quality and performance standards are met.

•            Develop and maintain records of appeals and grievances for reporting and auditing purposes.

•            Prepare and submit documents in response to fair hearings processes and requests; engage internal legal counsel as necessary.

•            Prepare and develop reports for, and present to, management related to appeals and grievances and fair hearings.

•            Ensure strict adherence to contractual requirements and Medicaid regulations, policies, and procedures.

•            Stay informed about changes in health care regulations related to appeals and grievances, and update processes accordingly.

•            Prepare and submit required reports to regulatory authorities regarding appeals, grievances and fair hearings activities.

•            Provide guidance, mentorship, and training to appeals, grievances, and risk management staff.

•            Foster a culture of compliance, quality improvement, and patient-centered care.

•            Identifies potential conflicts when reviewing and resolving appeals and grievances and escalates such conflicts to appropriate leader for review and resolution.

•            May perform other duties in addition to those outlined in this job description.

DC RESIDENTS ENCOURAGED TO APPLY

 

 

The disclosed salary range includes the minimum and maximum rates within which Children’s National believes an individual’s base pay rate will fall for this position. It is not typical for an individual to be hired at or near the maximum of the pay range. The exact pay rate for this position will be based on a variety of factors in alignment with the Children’s National compensation philosophy. These factors are legitimate and non-discriminatory including, but not limited to, the current market conditions; organizational needs; the individual’s combination of prior work experience, level of education, knowledge, skills, and other qualifications. Children’s National is committed to providing a fair and competitive total rewards package to each of our employees. This base salary range does not include our comprehensive benefits package or any additional compensation for which this position may be eligible.

 

Childrens National Hospital is an equal opportunity employer that evaluates qualified applicants without regard to race, color, national origin, religion, sex, age, marital status, disability, veteran status, sexual orientation, gender, identity, or other characteristics protected by law. The “Know Your Rights” poster is available here: and the pay transparency policy is available here: Know Your RightsPay Transparency Nondiscrimination Poster.

 

Please note that it is the policy of Children's National Hospital to ensure a “drug-free” work environment: a workplace free from the illegal use, possession or distribution of controlled substances (as defined in the Controlled Substances Act), or the misuse of legal substances, by all staff (management, employees and contractors). Though recreational and medical marijuana are now legal in the District of Columbia, Children's National and its affiliates maintain the right, in accordance with our policy, to enforce a drug-free workplace, including prohibiting recreational or prescribed marijuana.