Appeals Director

Requisition #: 322503
Location: Johns Hopkins Health Care, Hanover, MD 21076
Category: Leadership
Work Shift: Day Shift
Work Week: Full Time (40 hours)
Weekend Work Required: No
Date Posted: Jan. 26, 2021

Johns Hopkins HealthCare (JHHC) is the managed care and health services business of Johns Hopkins Medicine, one of the premier health delivery, academic, and research institutions in the United States. JHHC is a $2.5B business serving over 400,000 lives with lines of business in Medicaid, Medicare, commercial, military health, health solutions, and venture investments. JHHC has become a leader in provider-sponsored health plans and is poised for future growth.

Many organizations talk about transforming the future of healthcare, Johns Hopkins HealthCare is actually doing it. We develop innovative, analytics-driven health programs in collaboration with provider partners to drive improved quality and better health outcomes for the members and communities we serve. If you are interested in improving how healthcare is delivered, join the JHHC team.

POSITION SUMMARY:

Reporting to the Chief Medical Officer of Health Services the Appeals Director has responsibility for the effective operation of the appeals within JHHC. The Appeals Director will provide leadership and oversight to JHHC’s appeals function for all lines of business, including the processing of member appeals, provider appeals and payment disputes, as well as ensuring compliance with State regulations, clinical appropriateness of determinations, and quality of customer service. The Appeals Director will also oversee, and maintain relationships with outside physician reviewers. Duties include ongoing monitoring and tracking of department inventory; maintaining adequate staffing, ensuring adequate staff training and ongoing education; ensuring regulatory requirements are met.

Also establishes performance metrics for both the vendor and internal functions to ensure excellent service delivery to our members and providers. Also ensures 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 Appeals Director will serve as primary contact for state regulatory agencies and consumer advocacy agencies regarding member appeal issues.

COMPETENCIES:

A. Education:

Master of Science in health care related field

B. Knowledge:

Work requires knowledge of the health field and managed care case management/utilization management processes as acquired during five years of related experience with at least five years of management responsibilities. Comprehensive knowledge of CMS, DOL, COMAR and DOD regulations related to benefits and appeals. In-depth knowledge of data acquisition, data analysis, reporting, and use of data to make decisions is necessary.

C. Skills:

Work requires a high level of interpersonal skills to effectively interact with all levels of staff, clients, regulatory bodies, attorneys, etc.

Work collaboratively with other departments to solve problems, to improve processes, and to integrate services within other departments.

Lead, coordinate, and monitor policy and procedural changes and maintain the process for revision and implementation that supports plan regulatory compliance.

Assess departmental performance in relation to established goals and standards; recommend new approaches, workflows, policies and procedures to effect continual progress toward goals and standards.

Review and analyze appeals data along with audit results to improve root causes of member dissatisfaction and implement action plans and workflows for improvement to achieve member/provider satisfaction and operational effectiveness/efficiencies.

Perform audits to monitor compliance with policies and regulatory requirements, as well as ensuring process/operational efficiencies.

Report periodically on Appeals activities and trends to the Quality Assurance and Performance Improvement Committee.

Work requires excellent communication and writing skills.

D. Required Licensure, Certification, Etc.:

Active Maryland RN licensure required, if hired with a degree in nursing.

E. Work Experience

Work requires a minimum of five years of leadership experience which includes progressive management responsibilities in the areas of managed care, utilization management, quality management or claims management.

F. Machines, Tools, Equipment:

Must be able to operate general office and communications equipment. Must be computer literate.

A. Budget Responsibility:

Monitoring of departmental efficiency and waste. Manages an annual departmental budget of $1.5 million.

B. Authority/Decision Making Level:

Develops and recommends policies to senior management.

Makes decisions on staffing requests.

Make decisions regarding work processes based on established guidelines.

Prioritize work load of the appeals staff, and works independently with limited supervision.

C. Supervisory Responsibility:

Provide a supportive, inclusive, and team-first environment for the entire appeals and pended claims unit staff and appeals manager; Responsible for strategic and proactive hiring, performance management and coaching/mentoring/training to enhance professional development.

Provides guidance and direction to other departmental management and staff. Responsible for adequate scheduling and coverage of the appeals area.

Problem Solving:

Perform critical thinking as it relates to appeals and pend unit activities. Utilizes defined policies and procedures to ensure consistent application of appeals regulations and criteria. Diagnose operational challenges, implementing solutions where gaps are identified

Evaluate and recommend support strategies to meet system integration requirements

Oversee the design and analysis of organizational, divisional and departmental statistical reports on appeal volume, disposition and drivers are correct and presented throughout JHHC annually.

Information Management:

Must be able to use and understand medical records, UB92 forms and HCFA 1500 forms, benefits and regulations related to appeals.

Working Conditions:

Works in normal office environment where there are no physical discomforts dues to temperature, noise, dust, etc.

Work is sedentary in nature, however, some standing, stooping, bending, and walking is required. The position requires keyboard activity, pulling, filing, and duplicating.

Work requires minimal travel.

Johns Hopkins Health System and its affiliates are Equal Opportunity/Affirmative Action employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sexual orientation, gender identity, sex, age, national origin, disability, protected veteran status, and or any other status protected by federal, state, or local law.