CareFirst Careers

Manager, Clinical Appeals Medicare/Medicaid

Resp & Qualifications

PURPOSE:  Strategically manages the clinical appeals and grievances processed for members and member authorized representatives for Medicare Advantage, Medicaid, and other government programs. The incumbent is responsible for developing and overseeing a compliant clinical appeal and grievance process beginning with receipt of the appeal or grievance request through the decision, including all levels of the review process external to the Plan. The Manager will be accountable for developing and monitoring performance metrics to ensure Care Management is meeting the needs and requirements of our members, providers and Regulators. This individual is accountable for ensuring that appeal and grievance decisions are complete, timely, thorough, and accurate and in compliance with State, Federal and regulatory requirements, all the while being in alignment with CareFirst’s business strategy, and CMS Stars measures. The incumbent is responsible for responding to Insurance Commissioners, the Department of Labor and State, or Federal agencies regarding the appeal and grievance process and resultant decisions. The Manager will be charged with professionally interfacing with CareFirst Legal and Compliance for interpretation and implementation of mandates, regulations, statutes and assessment and execution of any regulatory decisions related to the clinical appeal process. The incumbent will be responsible for budget oversight and monitorization, including staff configuration to fulfill the primary goals of Health Services. 

Under the general direction of the Senior Director of Medical Review and Appeals, the incumbent’s accountabilities include, but are not limited to, the following:
1. Develop, establish and implement a process for intake, classification, and case development ensuring that appeals and grievances are fairly and properly resolved and corporate objectives for quality and regulatory compliance are achieved. Provide direct oversight of Medicare/Medicaid appeal and grievance staff ensuring timely and complete resolution of all appeals and grievances, including Regulatory complaints and reviews by an Independent Review Entity. Collaborates with Government Programs and provides indirect oversight of the back-office vendor.
2. Generate insights from data and translate to actions that support the compliant management of appeals and grievances and supports a uniform process. Regularly review and modify the appeal and grievance process, and implement changes, as appropriate, to ensure compliance with contractual, Regulatory, Federal and accreditation demands. Develop reporting processes to account for and monitor regulatory requirements and internal service level agreements. Provide oversight and monitoring, perform analytics and research, and review the processes and procedures between CareFirst and key internal and external strategic partners. Address issues with mutual impact, promote best practices, problem solve, facilitate resolution, and effectively integrate new processes as needed for appeals and grievances processed for members and member authorized representatives for Medicare Advantage and Medicaid.
3. Collaborate with Government Programs and Corporate Compliance to ensure compliance with Regulatory filings. Develop, implement, and monitor performance standards and documentation to ensure compliance with NCQA and State and Federal requirements for all functions within the scope of this position. When needed, serve as a direct liaison to the State or Federal regulatory agencies, providing open communication between all parties. 
4. Proactively involved in the review, interpretation, and implementation of new legislation that impacts Care Management. Provides support to Legal which includes evaluating, analyzing and rendering informed opinions regarding the delivery of health care, and the resulting outcomes. This may include but is not limited to, the preparation of chronologies of medical events in response to regulatory complaints and/or to assist Government Programs, Compliance, or Legal in preparation for disputes including attending and testifying on behalf of the Company. Responsible for drafting contract language for compliant claim, appeal or grievance management. Provide 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. Prepares and participates in appropriate presentations and educational/operational meetings.
5. In collaboration with the CAU Business Analysts, direct development of tracking, trending, and reporting information systems to identify appeal experience and appeals/complaint patterns in order to analyze and report data and important trends. Implement appropriate proactive interventions based on these findings. Responsible for the oversight, collection and analysis of data regarding appeals and grievances, including but not limited to standardized and adhoc performance reports, quarterly and annual reports to the Care Management and Quality Improvement Committees, Regulatory Agencies, Government Programs, Sales, and Healthcare Policy.
6. Institute, implement, monitor, and report on a fiscal budget to allocate and control expenses for the Division. Responsible for activities related to organization and development of the clinical appeal and grievance staff.

Required Education/Experience/Skills/Abilities:

• Licensed health care professional (RN, Pharm D, or related discipline)

In addition:
• At least 5 years’ experience with Medicare, Medicaid and other government programs.
• Minimum of 2 years’ in a managed care operational environment.
• At least 3 years’ experience as a people leader, directly managing staff.
• The incumbent must be self-directed; acting as a change agent and as such have results orientation, with an ability to work independently and make decisions in a dynamic environment dealing with internal and external issues.
• The ability to build and maintain key relationships in the community,
• Superior public speaking, organizational, verbal communication, and written skills.
• Must have highly developed analytical skills and must be able to effectively communicate complex reporting and business-related issues to a diverse audience (both written and orally).
• The incumbent must demonstrate a positive attitude with excellent interpersonal skills and the ability to deal with highly confidential and sensitive issues and possess negotiating skills, problem solving ability, and budget management skills.
• Must be able build productive relationships, be effective in individual and group meetings, be skilled in conflict resolution negotiations, and be able to lead and work effectively on cross-functional teams.
• Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. 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.
• This individual should have strong computer skills, including working knowledge of Microsoft Office programs. 
• The incumbent must have the ability to represent CareFirst BlueCross BlueShield in a professional manner both internally and externally. 

• Bachelor of Science or Master’s in Science Nursing or related field
• Leading people in an operations environment, as well as, clinical management.



• The physical demands described here are representative of those that must be met by the incumbent to perform the essential duties and responsibilities of the position successfully. Requirements may be modified to accommodate individuals with disabilities.
• Must be able to work in an office setting, primarily seated while performing duties for a minimum of 8 hours per workday.
• Must be able to provide own transportation to drive regularly to physician’s office and to satellite CareFirst Blue Cross Blue Shield offices.
• Walking and standing are required. Lift weight up to 25 pounds on occasion.
• Hands are regularly used to write, type, key and handle or feel small controls and objects.  Must be able to type and to speak on the telephone simultaneously.
• Must have the ability to communicate verbally effectively. Auditory ability to actively listen.

Equal Employment Opportunity: We are an Equal Employment Opportunity/Affirmative Action Employer and ADA compliant.

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.

Hire Range Disclaimer

Actual salary will be based on relevant job experience and work history.

Where To Apply

Please visit our website to apply:

Closing Date

Please apply before: 4/19/2020

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.


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

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