RN Manager Grievances & Appeals

As an RN Manager, Grievances & Appeals at Med Star Health, you will lead a team of nurses managing member grievances and appeals across a large, mission-driven health system. You will oversee timely, clinically sound case review, ensuring regulatory compliance and a patient-first approach. Partnering with physicians, quality, and care management teams, you'll analyze trends, refine workflows, and drive service and quality improvements.

This role offers robust training, career growth, and the opportunity to improve patient outcomes for diverse communities in the Maryland-Washington, D.C. region.

Responsibilities

• Lead and oversee the RN grievances and appeals program to ensure timely, accurate resolution of member concerns.
• Review complex clinical cases, applying evidence-based standards and regulatory requirements.
• Supervise and mentor RN staff, providing coaching, performance feedback, and professional development.
• Ensure compliance with federal, state, and payer regulations and internal Med
• Star Health policies.
• Collaborate with physicians, care managers, and interdisciplinary teams to resolve escalated cases.
• Monitor quality, turnaround times, and service metrics; implement process improvements as needed.
• Develop and update protocols, workflows, and documentation standards for grievances and appeals.
• Prepare reports and communicate trends, risks, and opportunities to leadership.
• Support training and education on grievance and appeal procedures and patient rights.
• Promote a patient-first, mission-driven culture focused on compassionate, equitable care.

Required Skills

• Clinical case review
• Grievance and appeals management
• Utilization management
• Healthcare regulatory compliance
• Quality improvement
• Team leadership and supervision
• Clinical documentation and reporting
• Managed care operations
• Data and trend analysis
• Interdisciplinary collaboration